Provider Demographics
NPI:1770768921
Name:KIMBALL, KERRY (EDD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-0757
Mailing Address - Country:US
Mailing Address - Phone:207-839-2587
Mailing Address - Fax:207-839-6469
Practice Address - Street 1:20 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1560
Practice Address - Country:US
Practice Address - Phone:207-839-2587
Practice Address - Fax:207-839-6469
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS574103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM0548Medicare PIN