MEDICARE: BETHANY MARIE KIMMEL BA, RBT, PSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	CG61455410	WA
2	101Y00000X	Counselor	CG61455410	WA
3	106S00000X	Behavior Technician	RBT-25-486252	GA
4	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1184313967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY MARIE KIMMEL BA, RBT, PSS

Provider Business Mailing Address
First Line	:	1400 BOXWOOD BLVD APT 5103
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-2345
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1933 WYNNTON RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31906-2964
Country	:	US
Telephone Number	:	843-338-0132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	10/29/2025

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