Provider Demographics
NPI:1023300464
Name:KIM, MICHELLE (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KIM
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:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:FL
Mailing Address - Zip Code:32949
Mailing Address - Country:US
Mailing Address - Phone:321-626-1083
Mailing Address - Fax:
Practice Address - Street 1:3556 PLUME WAY SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909
Practice Address - Country:US
Practice Address - Phone:321-626-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-10-3932103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst