Provider Demographics
NPI:1447513601
Name:BRAGG, KIMBERLY (SPECIAL ED TEACHER)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRAGG
Suffix:
Gender:F
Credentials:SPECIAL ED TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 ROYCROFT BLVD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4558
Mailing Address - Country:US
Mailing Address - Phone:716-839-2410
Mailing Address - Fax:
Practice Address - Street 1:5544 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5406
Practice Address - Country:US
Practice Address - Phone:716-580-3976
Practice Address - Fax:716-580-3976
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY560987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist