MEDICARE: RYAN SAMUEL KIMBALL PHD

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	103TC0700X	Clinical Psychologist	PSY.0005901	CO

General Provider Information

NPI Number	:	1336863216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN SAMUEL KIMBALL PHD

Provider Business Mailing Address
First Line	:	21825 E QUINCY AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80018-3155
Country	:	US
Telephone Number	:	720-723-3593
Fax Number	:

Provider Business Practice Location Address
First Line	:	21825 E QUINCY AVE
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80018-3155
Country	:	US
Telephone Number	:	720-723-3593
Fax Number	:

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

Provider Enumeration Date	:	10/03/2022
Last Update Date	:	03/26/2025

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