Provider Demographics
NPI:1992228688
Name:KIMBLE, MICKI ALENE
Entity type:Individual
Prefix:
First Name:MICKI
Middle Name:ALENE
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N. JT STITES BLVD.
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-9301
Mailing Address - Country:US
Mailing Address - Phone:918-775-7787
Mailing Address - Fax:918-775-0328
Practice Address - Street 1:205 S. JT STITES BLVD.
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9301
Practice Address - Country:US
Practice Address - Phone:918-775-7787
Practice Address - Fax:918-775-0328
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker