Provider Demographics
NPI:1396284451
Name:KIMBERLY RETHANS M.S., M.ED., BCBA
Entity type:Organization
Organization Name:KIMBERLY RETHANS M.S., M.ED., BCBA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RETHANS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MED, BCBA
Authorized Official - Phone:209-402-0427
Mailing Address - Street 1:661 EUCALYPTUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWMAN
Mailing Address - State:CA
Mailing Address - Zip Code:95360-9502
Mailing Address - Country:US
Mailing Address - Phone:209-402-0427
Mailing Address - Fax:
Practice Address - Street 1:661 EUCALYPTUS AVE
Practice Address - Street 2:
Practice Address - City:NEWMAN
Practice Address - State:CA
Practice Address - Zip Code:95360-9502
Practice Address - Country:US
Practice Address - Phone:209-402-0427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 106S00000X
CA1-14-17418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty