Provider Demographics
NPI:1972016566
Name:KIMBLE, KATY MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:MARIE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:MARIE
Other - Last Name:DEWAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 BRETON RD SE STE 102
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5220
Practice Address - Country:US
Practice Address - Phone:616-391-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801098860104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker