Healthcare Provider Details

I. General information

NPI: 1528920782
Provider Name (Legal Business Name): JANYIAH KELLISE WIMBERLY RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 ALLEN ST
OWENSBORO KY
42303-3437
US

IV. Provider business mailing address

301 E 9TH ST APT 15
OWENSBORO KY
42303-3601
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB989927
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: