Provider Demographics
NPI:1073497558
Name:PATRICK, KIMBERLY TAYLOR
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TAYLOR
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10289 BRIARBAY LOOP
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-6581
Mailing Address - Country:US
Mailing Address - Phone:770-864-0884
Mailing Address - Fax:
Practice Address - Street 1:3993 LAWRENCEVILLE HWY NW STE 110
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2831
Practice Address - Country:US
Practice Address - Phone:866-484-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB1291728106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician