Provider Demographics
NPI:1336945666
Name:KIMBALL, KEVIN L
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:KIMBALL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 W 11625 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7934
Mailing Address - Country:US
Mailing Address - Phone:801-509-4209
Mailing Address - Fax:
Practice Address - Street 1:760 NORTH 530 EAST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097
Practice Address - Country:US
Practice Address - Phone:801-687-9509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11552306-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist