Basic Information
| Provider Information | |||||||||
| NPI: | 1700420874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPPOLDT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ALEXIS | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13301 SW 2ND TER | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730997173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056641288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1212 S AIR DEPOT BLVD STE 17 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054556868 | ||||||||
| FaxNumber: | 8008560132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-103790 | OK | N | 103K00000X | 1-21-51557 | OK | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.