Healthcare Provider Details

I. General information

NPI: 1790659563
Provider Name (Legal Business Name): LISA C KIMBALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 121
KILL DEVIL HILLS NC
27948-0121
US

IV. Provider business mailing address

PO BOX 121
KILL DEVIL HILLS NC
27948-0121
US

V. Phone/Fax

Practice location:
  • Phone: 252-300-7267
  • Fax:
Mailing address:
  • Phone: 252-300-7267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA21934
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: