Provider Demographics
NPI:1073969283
Name:COGLIANO, KIMBYR
Entity Type:Individual
Prefix:
First Name:KIMBYR
Middle Name:
Last Name:COGLIANO
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 1:181 W. PROFESSIONAL PARK CT.
Mailing Address - Street 2:STE 1
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:130 CANAL ST STE 404
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4088
Practice Address - Country:US
Practice Address - Phone:912-988-1444
Practice Address - Fax:803-905-4431
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-9443103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst