Provider Demographics
NPI:1316375595
Name:KIMBALL, MICHAEL (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1923
Mailing Address - Country:US
Mailing Address - Phone:734-454-3560
Mailing Address - Fax:734-454-3570
Practice Address - Street 1:6635 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1029
Practice Address - Country:US
Practice Address - Phone:734-693-0554
Practice Address - Fax:419-517-1349
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-24
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07781103TC0700X
MI6301014600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294590Medicaid