Basic Information
| Provider Information | |||||||||
| NPI: | 1801186374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRWIN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.ED., BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 PACELLA PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023681755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814400400 | ||||||||
| FaxNumber: | 7815519880 | ||||||||
| Practice Location | |||||||||
| Address1: | 2533 HICKORY KNOLL LN | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232302129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709568511 | ||||||||
| FaxNumber: | 7709568907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 04/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.