Basic Information
| Provider Information | |||||||||
| NPI: | 1275768244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIMMEL | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 769 | ||||||||
| Address2: | 480 EVERSMAN DRIVE | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475470769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
| FaxNumber: | 8124826409 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 EVERSMAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475470769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
| FaxNumber: | 8124826409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 05/20/2009 | ||||||||
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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 | 1041C0700X | 34001093A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100108710A | 05 | IN | MEDICAID |