Provider Demographics
NPI:1699010298
Name:KIMBALL, CYNTHIA LOUISE (LMSW, ACSW, ACHP-SW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:LOUISE
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:LMSW, ACSW, ACHP-SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 3 MILE RD NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8209
Mailing Address - Country:US
Mailing Address - Phone:616-785-8900
Mailing Address - Fax:616-785-8949
Practice Address - Street 1:640 3 MILE RD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8209
Practice Address - Country:US
Practice Address - Phone:616-785-8900
Practice Address - Fax:616-785-8949
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010633021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical