Basic Information
| Provider Information | |||||||||
| NPI: | 1295072320 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CYNTHIA L KIMBALL, LMSW, ACSW, ACHP-SW, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 3 MILE RD NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495448209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167858900 | ||||||||
| FaxNumber: | 6167858949 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 3 MILE RD NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495448209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167858900 | ||||||||
| FaxNumber: | 6167858949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2013 | ||||||||
| LastUpdateDate: | 01/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | KIMBALL | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | LOUSIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 6167858900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LMSW, ACSW, ACHP-SW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.