Provider Demographics
NPI:1780228353
Name:DALLAS, KIMBERLY J
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:DALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:J
Other - Last Name:GRETTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 W CUMMINGS PARK STE 1900
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-6469
Mailing Address - Country:US
Mailing Address - Phone:339-227-4000
Mailing Address - Fax:781-634-6209
Practice Address - Street 1:600 W CUMMINGS PARK STE 1900
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6469
Practice Address - Country:US
Practice Address - Phone:339-227-4000
Practice Address - Fax:781-634-6209
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst