Provider Demographics
NPI:1417488396
Name:HAYCOCK, KIMBERLEE
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:
Last Name:HAYCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3848
Mailing Address - Street 2:1417 CACTU ST
Mailing Address - City:WENDOVER
Mailing Address - State:NV
Mailing Address - Zip Code:89883-3848
Mailing Address - Country:US
Mailing Address - Phone:775-934-2745
Mailing Address - Fax:
Practice Address - Street 1:1417 CACTUS ST
Practice Address - Street 2:
Practice Address - City:WENDOVER
Practice Address - State:NV
Practice Address - Zip Code:89883-3030
Practice Address - Country:US
Practice Address - Phone:775-934-2745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-16-13110106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician