Provider Demographics
NPI:1679606149
Name:BUMPER, KIMBERLY LOUISE
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:LOUISE
Last Name:BUMPER
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 1:115 FROST ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3441
Mailing Address - Country:US
Mailing Address - Phone:191-969-3796
Mailing Address - Fax:191-969-3696
Practice Address - Street 1:115 FROST ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3441
Practice Address - Country:US
Practice Address - Phone:191-969-3796
Practice Address - Fax:191-969-3696
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-039-042320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities