Provider Demographics
NPI:1093315962
Name:BUCHANAN, KIMBERLY MICHELE (DD RESIDENTIAL PROVI)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MICHELE
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:DD RESIDENTIAL PROVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 SUMMER WOOD LN
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7797
Mailing Address - Country:US
Mailing Address - Phone:330-990-2439
Mailing Address - Fax:234-294-0017
Practice Address - Street 1:1510 SUMMER WOOD LN
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-7797
Practice Address - Country:US
Practice Address - Phone:330-990-2439
Practice Address - Fax:234-294-0017
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7707468253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency