Provider Demographics
NPI:1275768244
Name:KIMMEL, EDWARD JOSEPH JR (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:KIMMEL
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 769
Mailing Address - Street 2:480 EVERSMAN DRIVE
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-0769
Mailing Address - Country:US
Mailing Address - Phone:812-482-3020
Mailing Address - Fax:812-482-6409
Practice Address - Street 1:480 EVERSMAN DRIVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47547-0769
Practice Address - Country:US
Practice Address - Phone:812-482-3020
Practice Address - Fax:812-482-6409
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001093A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100108710AMedicaid
212560HMedicare UPIN