Provider Demographics
NPI:1467972794
Name:GILL, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:GILL
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 1:862 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:327 W GORDON AVE STE 2
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2381
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2023-11-21
Deactivation Date:2023-11-01
Deactivation Code:
Reactivation Date:2023-11-21
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
UT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician