Provider Demographics
NPI:1720677305
Name:CROACH, KIMBERLY RENEE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:CROACH
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 1:3465 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-1534
Mailing Address - Country:US
Mailing Address - Phone:925-329-7826
Mailing Address - Fax:
Practice Address - Street 1:3465 GREGORY DR
Practice Address - Street 2:
Practice Address - City:BAY POINT
Practice Address - State:CA
Practice Address - Zip Code:94565-1534
Practice Address - Country:US
Practice Address - Phone:925-329-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 106E00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst