Provider Demographics
NPI:1962412601
Name:KIMBLE, MARILYN CECELIA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:CECELIA
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-2837
Mailing Address - Country:US
Mailing Address - Phone:404-508-2348
Mailing Address - Fax:
Practice Address - Street 1:1138 MELROSE DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-2837
Practice Address - Country:US
Practice Address - Phone:404-508-2348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA61-00158OtherEVERCARE CHOICE PROVIDER
GA61-00158OtherEVERCARE CHOICE PROVIDER