Provider Demographics
NPI:1306087770
Name:KIMBALL, JUDITH (PHD,OTR)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PHD,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2140
Mailing Address - Country:US
Mailing Address - Phone:207-283-1954
Mailing Address - Fax:207-283-1954
Practice Address - Street 1:441 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-2140
Practice Address - Country:US
Practice Address - Phone:207-283-1954
Practice Address - Fax:207-283-1954
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT138225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME252130099Medicaid
ME252130099Medicaid