Provider Demographics
NPI:1255044541
Name:PEARSON, KIMBRA
Entity type:Individual
Prefix:
First Name:KIMBRA
Middle Name:
Last Name:PEARSON
Suffix:
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 1:1613 BROOKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2585
Practice Address - Country:US
Practice Address - Phone:470-944-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician