MEDICARE: MRS. DIANE MARY KIMBALL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	24284	TX
2	106H00000X	Marriage & Family Therapist	24284	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24284	OTHER	TX	TX STATE BD OF EXAM SW
2	00S99X	OTHER	TX	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1295844801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE MARY KIMBALL LCSW

Provider Business Mailing Address
First Line	:	522 MYSTIC SHORES BLVD
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-5240
Country	:	US
Telephone Number	:	210-385-0063
Fax Number	:	210-333-0565

Provider Business Practice Location Address
First Line	:	1550 NE LOOP 410
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1610
Country	:	US
Telephone Number	:	210-385-0063
Fax Number	:	210-333-0565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	09/11/2025

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