Provider Demographics
NPI:1376871194
Name:WOLFF, KIM PHAN (MS, BCBA, COBA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:PHAN
Last Name:WOLFF
Suffix:
Gender:F
Credentials:MS, BCBA, COBA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3505 EMBASSY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-8403
Mailing Address - Country:US
Mailing Address - Phone:302-716-1073
Mailing Address - Fax:330-706-4705
Practice Address - Street 1:3505 EMBASSY PKWY
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-8405
Practice Address - Country:US
Practice Address - Phone:330-271-6107
Practice Address - Fax:330-706-4705
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOBA.91103K00000X
TN1096600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-09-6600OtherBCBA CERTIFICATE