Provider Demographics
NPI:1114254661
Name:KIMBALL, LINDA A (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3493 WOODS EDGE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864
Mailing Address - Country:US
Mailing Address - Phone:517-886-3707
Mailing Address - Fax:517-349-1973
Practice Address - Street 1:3493 WOODS EDGE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-886-3707
Practice Address - Fax:517-349-1973
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010700991041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P40800-013Medicare PIN