Healthcare Provider Details

I. General information

NPI: 1972913853
Provider Name (Legal Business Name): KIMBERLY MARIE GEORGE BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16414 SOUTHPARK DR
WESTFIELD IN
46074
US

IV. Provider business mailing address

16414 SOUTHPARK DR
WESTFIELD IN
46074
US

V. Phone/Fax

Practice location:
  • Phone: 812-361-6623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-14-5943
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: