Provider Demographics
NPI:1740911924
Name:PROVOST, KIMBERLY ANNE (BCABA)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANNE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:PROVOST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:147 ALLEN BROOK LN STE 104
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9211
Mailing Address - Country:US
Mailing Address - Phone:802-876-7111
Mailing Address - Fax:802-448-6905
Practice Address - Street 1:147 ALLEN BROOK LN STE 104
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9211
Practice Address - Country:US
Practice Address - Phone:802-876-7111
Practice Address - Fax:802-448-6905
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst