Basic Information
| Provider Information | |||||||||
| NPI: | 1346976891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL KIMBALL INTEGRATIVE PSYCHOTHERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7040 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435601923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346930554 | ||||||||
| FaxNumber: | 4195171349 | ||||||||
| Practice Location | |||||||||
| Address1: | 6635 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195170105 | ||||||||
| FaxNumber: | 4195171349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | KIMBALL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7346930554 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0294590 | 05 | OH | MEDICAID |