Provider Demographics
NPI:1386087930
Name:JARUTOWICZ, KIMBERLEY GRAHAM (BCBA)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:GRAHAM
Last Name:JARUTOWICZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 COUNTY ROAD 314
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-3340
Mailing Address - Country:US
Mailing Address - Phone:210-289-7686
Mailing Address - Fax:186-640-3798
Practice Address - Street 1:2525 LADD ST BLDG 3850
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-5308
Practice Address - Country:US
Practice Address - Phone:210-289-7686
Practice Address - Fax:186-640-3798
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-14
Last Update Date:2013-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-12822103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1-13-12822OtherBCBA CERTIFICATE NUMBER