Provider Demographics
NPI:1912760372
Name:KIMBLE, MARY LYNETTE (SWT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNETTE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:SWT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNETTE
Other - Last Name:HAMPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5672 VICKIE LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-2415
Mailing Address - Country:US
Mailing Address - Phone:216-343-8069
Mailing Address - Fax:
Practice Address - Street 1:21625 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5363
Practice Address - Country:US
Practice Address - Phone:216-343-8069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2403415-TRNE101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health