Provider Demographics
NPI:1114102365
Name:SALLS, KIMBERLY ANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:SALLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5389 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1401
Mailing Address - Country:US
Mailing Address - Phone:314-772-6933
Mailing Address - Fax:314-772-5858
Practice Address - Street 1:5389 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1401
Practice Address - Country:US
Practice Address - Phone:314-772-6933
Practice Address - Fax:314-772-5858
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-04-1947103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856074703Medicaid