Provider Demographics
NPI:1033861091
Name:KIMBLE, KHELICITY
Entity Type:Individual
Prefix:
First Name:KHELICITY
Middle Name:
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CEDAR HILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5900
Mailing Address - Country:US
Mailing Address - Phone:214-901-0152
Mailing Address - Fax:
Practice Address - Street 1:5401 CHIMNEY ROCK RD APT 408
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-2023
Practice Address - Country:US
Practice Address - Phone:214-901-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician