1295844801 NPI number — MRS. DIANE MARY KIMBALL LCSW

Table of content: MRS. DIANE MARY KIMBALL LCSW (NPI 1295844801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295844801 NPI number — MRS. DIANE MARY KIMBALL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIMBALL
Provider First Name:
DIANE
Provider Middle Name:
MARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295844801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
522 MYSTIC SHORES BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING BRANCH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78070-5240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-385-0063
Provider Business Mailing Address Fax Number:
210-333-0565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1550 NE LOOP 410
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78209-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-385-0063
Provider Business Practice Location Address Fax Number:
210-333-0565
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  24284 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 24284 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 24284 . This is a "TX STATE BD OF EXAM SW" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00S99X . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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