Provider Demographics
NPI:1902464282
Name:HORTON, KIMBALL
Entity type:Individual
Prefix:
First Name:KIMBALL
Middle Name:
Last Name:HORTON
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 1:8285 S SAGINAW ST STE 7
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2436
Mailing Address - Country:US
Mailing Address - Phone:810-321-3001
Mailing Address - Fax:
Practice Address - Street 1:8285 S SAGINAW ST STE 7
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2436
Practice Address - Country:US
Practice Address - Phone:810-321-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician