Provider Demographics
NPI:1164884888
Name:KIMBALL, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KIMBALL
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 1:5467 RONALD REAGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-6332
Mailing Address - Country:US
Mailing Address - Phone:407-324-3036
Mailing Address - Fax:407-324-3045
Practice Address - Street 1:5467 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6332
Practice Address - Country:US
Practice Address - Phone:407-324-3036
Practice Address - Fax:407-324-3045
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health