Provider Demographics
NPI:1487918686
Name:BRANTLEY, KIM (ABA THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:ABA THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6039
Mailing Address - Country:US
Mailing Address - Phone:718-966-8365
Mailing Address - Fax:
Practice Address - Street 1:1634 ARDEN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6039
Practice Address - Country:US
Practice Address - Phone:718-966-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709609174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist