=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902791973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY DERQUE BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2025
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 TRIAD CENTER DR
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-7357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-248-7841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4848 DALTREY CT
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63129-1655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-524-2136
-----------------------------------------------------
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 | 894991
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------