Provider Demographics
NPI:1922081793
Name:KIMMELL, KRISTIN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:KIMMELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N WALNUT ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3982
Mailing Address - Country:US
Mailing Address - Phone:812-332-6992
Mailing Address - Fax:
Practice Address - Street 1:205 N WALNUT ST
Practice Address - Street 2:SUITE 800
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3982
Practice Address - Country:US
Practice Address - Phone:812-332-6992
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000505A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN546570Medicare ID - Type Unspecified