Provider Demographics
NPI:1861110330
Name:KIMBALL, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 LITTLE POND PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 SPENCE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3830
Practice Address - Country:US
Practice Address - Phone:832-457-2544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0881101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program