Provider Demographics
NPI:1811761216
Name:KIMBRELL, MICHELLE DENISE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:KIMBRELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DENISE
Other - Last Name:PETTIJOHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3220 KHYBER CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3957
Mailing Address - Country:US
Mailing Address - Phone:907-830-6112
Mailing Address - Fax:
Practice Address - Street 1:3220 KHYBER CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3957
Practice Address - Country:US
Practice Address - Phone:907-830-6112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCSWS12821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical