Provider Demographics
NPI:1629399795
Name:EDWARDS, KIMBERLY (BCBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:EDWARDS
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 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:2700 HIGHWAY 34 E STE 100
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2315
Practice Address - Country:US
Practice Address - Phone:470-394-0004
Practice Address - Fax:470-241-1269
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 251S00000X, 252Y00000X
GA1-18-33584103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency