Provider Demographics
NPI:1548923089
Name:KIMBALL, AMY SUSAN (CADC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUSAN
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1134
Mailing Address - Country:US
Mailing Address - Phone:207-949-7408
Mailing Address - Fax:
Practice Address - Street 1:518 NORTH ST
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-1134
Practice Address - Country:US
Practice Address - Phone:207-949-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC7769101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)