1174043475 NPI number — KIMBERLY ANN TABACHKA BEHAVIOR ASSISTANT

Table of content: KIMBERLY ANN TABACHKA BEHAVIOR ASSISTANT (NPI 1174043475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174043475 NPI number — KIMBERLY ANN TABACHKA BEHAVIOR ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TABACHKA
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BEHAVIOR ASSISTANT
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:
1174043475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 PRIMERA BLVD STE 160B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-2158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 PRIMERA BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 160B
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-440-0500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2017

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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