MEDICARE: KIMBERLY ANN GARDNER B.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1245766799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ANN GARDNER B.A.

Provider Business Mailing Address
First Line	:	3941 DE SABLA RD
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-8604
Country	:	US
Telephone Number	:	916-420-0512
Fax Number	:

Provider Business Practice Location Address
First Line	:	3941 DE SABLA RD
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-8604
Country	:	US
Telephone Number	:	916-420-0512
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	05/03/2017

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