=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174078984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. PEGGY LYNN KIRBY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2016
-----------------------------------------------------
Last Update Date | 08/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 11TH CT
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32962-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-532-8321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 11TH CT
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32962-2837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-532-8321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 0-03-0734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------