Healthcare Provider Details

I. General information

NPI: 1417488396
Provider Name (Legal Business Name): KIMBERLEE HAYCOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 CACTUS ST
WENDOVER NV
89883-3030
US

IV. Provider business mailing address

PO BOX 3848 1417 CACTU ST
WENDOVER NV
89883-3848
US

V. Phone/Fax

Practice location:
  • Phone: 775-934-2745
  • Fax:
Mailing address:
  • Phone: 775-934-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-13110
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: