Provider Demographics
NPI:1295844801
Name:KIMBALL, DIANE MARY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARY
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 MYSTIC SHORES BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-5240
Mailing Address - Country:US
Mailing Address - Phone:210-385-0063
Mailing Address - Fax:210-333-0565
Practice Address - Street 1:1550 NE LOOP 410
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1610
Practice Address - Country:US
Practice Address - Phone:210-385-0063
Practice Address - Fax:210-333-0565
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24284101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX24284OtherTX STATE BD OF EXAM SW
TX00S99XOtherBCBS PROVIDER NUMBER