Provider Demographics
NPI:1629616172
Name:ROLLER, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:ROLLER
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 1:2222 SCHILLER RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9747
Mailing Address - Country:US
Mailing Address - Phone:360-990-1483
Mailing Address - Fax:
Practice Address - Street 1:2222 SCHILLER RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9747
Practice Address - Country:US
Practice Address - Phone:360-990-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAD003734N103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst