Provider Demographics
NPI:1619305794
Name:WOOLERY, KIMBERLY (BCBA)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:
Last Name:WOOLERY
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 1:8041 NW 10TH CT # 19-8041
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5706
Mailing Address - Country:US
Mailing Address - Phone:786-740-5903
Mailing Address - Fax:
Practice Address - Street 1:612 NE 57TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2320
Practice Address - Country:US
Practice Address - Phone:954-272-8983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22354101YM0800X
ZZ1-13-14362103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103159800Medicaid