Provider Demographics
NPI:1669680880
Name:KIMBLE, MARY ELLEN (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5057 EASTWIND LN
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6216
Mailing Address - Country:US
Mailing Address - Phone:814-833-7490
Mailing Address - Fax:
Practice Address - Street 1:306 W 11TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1746
Practice Address - Country:US
Practice Address - Phone:814-456-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional