Healthcare Provider Details

I. General information

NPI: 1801067400
Provider Name (Legal Business Name): KIMBERLY ANN WILLIAMSON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 E EMPIRE ST SUITE G
BLOOMINGTON IL
61704-3706
US

IV. Provider business mailing address

2203 E EMPIRE ST SUITE G
BLOOMINGTON IL
61704-3706
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-5050
  • Fax: 630-303-9704
Mailing address:
  • Phone: 309-662-5050
  • Fax: 630-303-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-07-3716
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: