Provider Demographics
NPI:1811366610
Name:HUBER, KIMBERLY J (MSED, LMFTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HUBER
Suffix:
Gender:F
Credentials:MSED, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16143 GEMMA PASS
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9146
Mailing Address - Country:US
Mailing Address - Phone:260-715-0536
Mailing Address - Fax:
Practice Address - Street 1:2200 LAKE AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5397
Practice Address - Country:US
Practice Address - Phone:260-424-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000212A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist