Basic Information
| Provider Information | |||||||||
| NPI: | 1316375595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7040 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435601923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344543560 | ||||||||
| FaxNumber: | 7344543570 | ||||||||
| Practice Location | |||||||||
| Address1: | 6635 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346930554 | ||||||||
| FaxNumber: | 4195171349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 07781 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6301014600 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0294590 | 05 | OH | MEDICAID |