MEDICARE: MRS. KIMBERLY SUE IRWIN M.ED., BCABA

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	:	1801186374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY SUE IRWIN M.ED., BCABA

Provider Business Mailing Address
First Line	:	41 PACELLA PARK DR
Second Line	:
City	:	RANDOLPH
State	:	MA
Zip	:	02368-1755
Country	:	US
Telephone Number	:	781-440-0400
Fax Number	:	781-551-9880

Provider Business Practice Location Address
First Line	:	2533 HICKORY KNOLL LN
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-2129
Country	:	US
Telephone Number	:	770-956-8511
Fax Number	:	770-956-8907

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

Provider Enumeration Date	:	04/18/2011
Last Update Date	:	04/18/2011

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