Provider Demographics
NPI:1700546710
Name:KIMBALL, ERICA PENICK
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:PENICK
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 1:10433 CHESTERTON DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-2205
Mailing Address - Country:US
Mailing Address - Phone:214-801-3061
Mailing Address - Fax:
Practice Address - Street 1:8150 N CENTRAL EXPY STE M-1065
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-1815
Practice Address - Country:US
Practice Address - Phone:214-736-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-19
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20101101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor