Provider Demographics
NPI:1578287314
Name:KIRBY, KIMBERLY J
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:KIRBY
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 1:108 JEFFERSON CT
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1544
Mailing Address - Country:US
Mailing Address - Phone:859-358-2059
Mailing Address - Fax:
Practice Address - Street 1:108 JEFFERSON CT
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1544
Practice Address - Country:US
Practice Address - Phone:859-358-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1186485175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1186485Medicaid