Provider Demographics
NPI:1639618879
Name:SMITH, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:2098 SEMINOLE BLVD APT 3408
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-1724
Mailing Address - Country:US
Mailing Address - Phone:727-772-3927
Mailing Address - Fax:800-713-8330
Practice Address - Street 1:5030 78TH AVE N STE 11
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2406
Practice Address - Country:US
Practice Address - Phone:727-545-1273
Practice Address - Fax:800-713-8330
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid