Healthcare Provider Details

I. General information

NPI: 1063595767
Provider Name (Legal Business Name): MARILYN PAYNE KIMBREL LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 WALES AVE NW SUITE K
MASSILLON OH
44646-0804
US

IV. Provider business mailing address

2400 WALES AVE NW SUITE K
MASSILLON OH
44646-0804
US

V. Phone/Fax

Practice location:
  • Phone: 330-833-2452
  • Fax: 330-833-2749
Mailing address:
  • Phone: 330-833-2452
  • Fax: 330-833-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE2177
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: