Provider Demographics
NPI:1700420874
Name:LIPPOLDT, KIMBERLY ALEXIS (BCBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ALEXIS
Last Name:LIPPOLDT
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 1:13301 SW 2ND TER
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-7173
Mailing Address - Country:US
Mailing Address - Phone:405-664-1288
Mailing Address - Fax:
Practice Address - Street 1:13905 TECHNOLOGY DR STE A1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1054
Practice Address - Country:US
Practice Address - Phone:405-455-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-19-103790106S00000X
OK1-21-51557103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician