Healthcare Provider Details

I. General information

NPI: 1629930797
Provider Name (Legal Business Name): MCKAYLA MARIE KIMBALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 LOLA AVE
ALTAVISTA VA
24517-1352
US

IV. Provider business mailing address

1872 STATE ROUTE 30
NORTH BLENHEIM NY
12131-1604
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-6651
  • Fax:
Mailing address:
  • Phone: 518-545-7455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number030599
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC021220
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119011228
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: