Provider Demographics
NPI:1932473212
Name:KIMBALL, MICAELA REID
Entity Type:Individual
Prefix:MS
First Name:MICAELA
Middle Name:REID
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TURNER ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5299
Mailing Address - Country:US
Mailing Address - Phone:207-376-3233
Mailing Address - Fax:
Practice Address - Street 1:600 TURNER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-5299
Practice Address - Country:US
Practice Address - Phone:207-376-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-03
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4779225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist