Provider Demographics
NPI:1104233766
Name:KIMBELL, LINDA CALVO (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:CALVO
Last Name:KIMBELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 AMERICAN WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6611
Mailing Address - Country:US
Mailing Address - Phone:770-995-7622
Mailing Address - Fax:
Practice Address - Street 1:119 HARMONY XING STE 3
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9571
Practice Address - Country:US
Practice Address - Phone:706-817-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0052031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003150127AMedicaid
GA003150127BMedicaid
GA202I801959Medicare PIN