1033485123 NPI number — MRS. KIMBERLY ELLISON DE JONG M.S., BCBA

Table of content: MRS. KIMBERLY ELLISON DE JONG M.S., BCBA (NPI 1033485123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033485123 NPI number — MRS. KIMBERLY ELLISON DE JONG M.S., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE JONG
Provider First Name:
KIMBERLY
Provider Middle Name:
ELLISON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033485123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15905 CHATEAU AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-418-2233
Provider Business Mailing Address Fax Number:
301-263-6870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15905 CHATEAU AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78734-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-418-2233
Provider Business Practice Location Address Fax Number:
301-263-6870
Provider Enumeration Date:
03/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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