Provider Demographics
NPI:1871398990
Name:KIMBALL, LAURA CAMILLE (PPS)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:CAMILLE
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4671 LA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-4160
Mailing Address - Country:US
Mailing Address - Phone:541-821-0063
Mailing Address - Fax:
Practice Address - Street 1:1500 D ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2346
Practice Address - Country:US
Practice Address - Phone:541-821-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250031648101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool