Provider Demographics
NPI:1164075776
Name:ZIMMERMAN, EVAN RAY (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:RAY
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:EVAN
Other - Middle Name:RAY
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA, RBT
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:
Practice Address - Street 1:1300 E NEW CIRCLE ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-9001
Practice Address - Country:US
Practice Address - Phone:859-685-1019
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267949103K00000X
1-20-46370103K00000X
RBT-15-01898106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-46370OtherBCBA CERTIFICATE
RBT-15-01898OtherRBT CERTIFICATE