Provider Demographics
NPI:1346847779
Name:BREDBERG-BEANER, KIMBERLY KAY (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:KAY
Last Name:BREDBERG-BEANER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-2722
Mailing Address - Country:US
Mailing Address - Phone:140-951-2562
Mailing Address - Fax:
Practice Address - Street 1:2200 BOX ELDER ST STE 151
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5930
Practice Address - Country:US
Practice Address - Phone:406-234-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-BA-LIC-3394103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-45009OtherBACB