Provider Demographics
NPI:1952818452
Name:CORNMAN, KIMBERLY PAIGE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:CORNMAN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 FLOWING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8509
Mailing Address - Country:US
Mailing Address - Phone:260-403-7056
Mailing Address - Fax:
Practice Address - Street 1:4935 HILLEGAS RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1934
Practice Address - Country:US
Practice Address - Phone:260-338-1241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-28812103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst