Basic Information
| Provider Information | |||||||||
| NPI: | 1629399795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 4075886294 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 HIGHWAY 34 E STE 100 | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703940004 | ||||||||
| FaxNumber: | 4702411269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251S00000X | N | Agencies | Community/Behavioral Health | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 103K00000X | 1-18-33584 | GA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.