Provider Demographics
NPI:1801067400
Name:WILLIAMSON, KIMBERLY ANN (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 E EMPIRE ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3706
Mailing Address - Country:US
Mailing Address - Phone:309-662-5050
Mailing Address - Fax:630-303-9704
Practice Address - Street 1:2203 E EMPIRE ST
Practice Address - Street 2:SUITE G
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3706
Practice Address - Country:US
Practice Address - Phone:309-662-5050
Practice Address - Fax:630-303-9704
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-07-3716103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1-07-3716OtherBACB CERTIFICANT