Provider Demographics
NPI:1427396100
Name:ROSE, KIMBERLY CHRISTINE (MS BCBA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CHRISTINE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 BALLARK ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-8817
Mailing Address - Country:US
Mailing Address - Phone:352-409-1202
Mailing Address - Fax:
Practice Address - Street 1:1650 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2841
Practice Address - Country:US
Practice Address - Phone:302-740-1287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-06-3047103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst