Provider Demographics
NPI:1114418852
Name:POPOVICH, KIMBERLY ANN (BSL, MED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:POPOVICH
Suffix:
Gender:F
Credentials:BSL, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 SEIDERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-4219
Mailing Address - Country:US
Mailing Address - Phone:484-264-0966
Mailing Address - Fax:
Practice Address - Street 1:5300 KIDSPEACE DR
Practice Address - Street 2:
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2098
Practice Address - Country:US
Practice Address - Phone:484-264-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002162103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH002162OtherBUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS