Provider Demographics
NPI:1134859499
Name:KIMBALL, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 MISSISSIPPI CIR N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1267
Mailing Address - Country:US
Mailing Address - Phone:763-331-2961
Mailing Address - Fax:
Practice Address - Street 1:501 23RD AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0447
Practice Address - Country:US
Practice Address - Phone:763-331-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
JZH133820080001OtherBLUECROSS BLUESHIELD