Provider Demographics
NPI:1215502364
Name:KIMBRELL, MICHELLE MAE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MAE
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1527
Mailing Address - Country:US
Mailing Address - Phone:517-260-1784
Mailing Address - Fax:
Practice Address - Street 1:505 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1527
Practice Address - Country:US
Practice Address - Phone:517-260-1784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010892225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist