Provider Demographics
NPI:1366914558
Name:KIMBALL, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ROBINHOOD DR
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0600
Mailing Address - Country:US
Mailing Address - Phone:207-478-6992
Mailing Address - Fax:
Practice Address - Street 1:557 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4511
Practice Address - Country:US
Practice Address - Phone:207-973-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC6779101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty