Provider Demographics
NPI:1740257021
Name:KIMBELL, CHARLES A (PHD, HSPP)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:KIMBELL
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 S CLARIZZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5523
Mailing Address - Country:US
Mailing Address - Phone:812-355-5890
Mailing Address - Fax:812-355-5895
Practice Address - Street 1:655 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5523
Practice Address - Country:US
Practice Address - Phone:812-355-5890
Practice Address - Fax:812-355-5895
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040582103TC0700X, 103T00000X
TX33522103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000316234OtherANTHEM
IN100332490AMedicaid
IN100332490AMedicaid