Provider Demographics
NPI:1376231399
Name:KIMBROUGH, JAMES D JR
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:KIMBROUGH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16700 17 MILE RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7325
Mailing Address - Country:US
Mailing Address - Phone:586-228-2300
Mailing Address - Fax:586-228-2307
Practice Address - Street 1:16700 17 MILE RD STE A
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-7325
Practice Address - Country:US
Practice Address - Phone:586-228-2300
Practice Address - Fax:586-228-2307
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIK516367135288106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician