Basic Information
| Provider Information | |||||||||
| NPI: | 1164075776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMMERMAN | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MED, BCBA, LBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZIMMERMAN | ||||||||
| OtherFirstName: | EVAN | ||||||||
| OtherMiddleName: | RAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BA, RBT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 E NEW CIRCLE ROAD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405059001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596851019 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2019 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 267949 | KY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-20-46370 | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-20-46370 | 01 | BCBA CERTIFICATE | OTHER |