Basic Information
| Provider Information | |||||||||
| NPI: | 1073598629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | KIMBLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 7165 CLEARVISTA WAY | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215756 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 03/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39000004A | IN | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 34002814A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 35000369A | IN | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.