=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629930797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MCKAYLA MARIE KIMBALL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2025
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1317 LOLA AVE
-----------------------------------------------------
City | ALTAVISTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24517-1352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-369-6651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1872 STATE ROUTE 30
-----------------------------------------------------
City | NORTH BLENHEIM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12131-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-545-7455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 030599
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC021220
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 0119011228
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------