Provider Demographics
NPI:1801019013
Name:KIMBRELL, KELLY (MA, CAGS)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:KIMBRELL
Suffix:
Gender:M
Credentials:MA, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3733 E WATERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7882
Mailing Address - Country:US
Mailing Address - Phone:480-768-7624
Mailing Address - Fax:
Practice Address - Street 1:1331 E REDFIELD RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-4133
Practice Address - Country:US
Practice Address - Phone:480-783-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool