Provider Demographics
NPI:1902294721
Name:KIMBLE, ANQUINETTE MONIQUE (MSW)
Entity type:Individual
Prefix:
First Name:ANQUINETTE
Middle Name:MONIQUE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 KINGSTON RD
Mailing Address - Street 2:APT B
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-3907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 KINGSTON RD
Practice Address - Street 2:APT B
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-3907
Practice Address - Country:US
Practice Address - Phone:267-253-2976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor