Provider Demographics
NPI:1508967985
Name:KIMMEL, MICHAEL DALE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DALE
Last Name:KIMMEL
Suffix:
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 1:5100 MARLBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-2020
Mailing Address - Country:US
Mailing Address - Phone:619-582-0771
Mailing Address - Fax:619-584-4697
Practice Address - Street 1:5100 MARLBOROUGH DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2020
Practice Address - Country:US
Practice Address - Phone:619-582-0771
Practice Address - Fax:619-584-4697
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW#207381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical