Provider Demographics
NPI:1750870234
Name:ANDERSON, KIMBERLY T (BCBA, LABA, LMHC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BCBA, LABA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CTR
Mailing Address - Street 2:SUITE 135H
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6127
Mailing Address - Country:US
Mailing Address - Phone:978-927-0172
Mailing Address - Fax:978-927-0179
Practice Address - Street 1:100 CUMMINGS CTR STE 135H
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6127
Practice Address - Country:US
Practice Address - Phone:978-927-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA996103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA996OtherLABA LICENSE