Provider Demographics
NPI:1619380961
Name:TROUTMAN, KIMMESHA (BCBA)
Entity Type:Individual
Prefix:
First Name:KIMMESHA
Middle Name:
Last Name:TROUTMAN
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 1:420 E SR 434 STE A
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5244
Mailing Address - Country:US
Mailing Address - Phone:407-476-4908
Mailing Address - Fax:844-839-5839
Practice Address - Street 1:420 E SR 434 STE A
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5244
Practice Address - Country:US
Practice Address - Phone:407-476-4908
Practice Address - Fax:844-839-5839
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-19-36525103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017645000Medicaid