Healthcare Provider Details

I. General information

NPI: 1619305794
Provider Name (Legal Business Name): KIMBERLY WOOLERY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2013
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 REDLAND CT
OWINGS MILLS MD
21117-3264
US

IV. Provider business mailing address

175 BELGROVE DR
KEARNY NJ
07032-1507
US

V. Phone/Fax

Practice location:
  • Phone: 201-979-1336
  • Fax:
Mailing address:
  • Phone: 201-979-1336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH22354
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14362
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: