Basic Information
| Provider Information | |||||||||
| NPI: | 1073969283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COGLIANO | ||||||||
| FirstName: | KIMBYR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 W. PROFESSIONAL PARK CT. | ||||||||
| Address2: | STE 1 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707779283 | ||||||||
| FaxNumber: | 2707779283 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 CANAL ST STE 404 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313224088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129881444 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2016 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-9443 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.