Basic Information
| Provider Information | |||||||||
| NPI: | 1194233056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BILLINGS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENNESSY | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3208 GULF BREEZE PKWY | ||||||||
| Address2: | |||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325633350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006765130 | ||||||||
| FaxNumber: | 8889585753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 CROFTON BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | CROFTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211141314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006765130 | ||||||||
| FaxNumber: | 8889585753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2018 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 106S00000X | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.