Healthcare Provider Details

I. General information

NPI: 1962175406
Provider Name (Legal Business Name): KIMBERLY PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BROADUS AVE
GREENVILLE SC
29601-3040
US

IV. Provider business mailing address

120 BROADUS AVE
GREENVILLE SC
29601-3040
US

V. Phone/Fax

Practice location:
  • Phone: 864-752-9123
  • Fax:
Mailing address:
  • Phone: 864-752-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-24-15032
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-109697
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-82515
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: