Healthcare Provider Details

I. General information

NPI: 1376871194
Provider Name (Legal Business Name): KIM PHAN WOLFF M.S., BCBA, COBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM PHAN M.S.

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 EMBASSY PKWY
FAIRLAWN OH
44333-8405
US

IV. Provider business mailing address

3505 EMBASSY PKWY STE 100
FAIRLAWN OH
44333-8403
US

V. Phone/Fax

Practice location:
  • Phone: 330-271-6107
  • Fax: 330-706-4705
Mailing address:
  • Phone: 302-716-1073
  • Fax: 330-706-4705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberCOBA.91
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: