Provider Demographics
NPI:1023849171
Name:BEACH, KIMBERLY RENEE I
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:BEACH
Suffix:I
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:W849 PRIMROSE RD
Mailing Address - Street 2:
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-1647
Mailing Address - Country:US
Mailing Address - Phone:262-729-6009
Mailing Address - Fax:
Practice Address - Street 1:200 N PATRICK BLVD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5883
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIRBT-23-312893106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician