Provider Demographics
NPI:1083036107
Name:PETERS, KIMBERLY ANN (BCBA, MS)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:PETERS
Suffix:
Gender:F
Credentials:BCBA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GUMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-6921
Mailing Address - Country:US
Mailing Address - Phone:318-623-0587
Mailing Address - Fax:
Practice Address - Street 1:3602 CYPRESS ST STE D
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7314
Practice Address - Country:US
Practice Address - Phone:318-396-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1-13-14844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13-14844OtherBACB