Provider Demographics
NPI:1851511430
Name:KIMBRELL, GORDON M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:M
Last Name:KIMBRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 JOHNNIE DODDS BLVD
Mailing Address - Street 2:SUITE 14-B
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-884-3888
Mailing Address - Fax:843-884-8124
Practice Address - Street 1:1041 JOHNNIE DODDS BLVD
Practice Address - Street 2:SUITE 14-B
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-884-3888
Practice Address - Fax:843-884-8124
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC325103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical