Provider Demographics
NPI:1689494536
Name:EBANKS PELLEGRINO, KIMOUYA ANICIA
Entity type:Individual
Prefix:
First Name:KIMOUYA
Middle Name:ANICIA
Last Name:EBANKS PELLEGRINO
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 1:2484 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5743
Mailing Address - Country:US
Mailing Address - Phone:561-501-9224
Mailing Address - Fax:
Practice Address - Street 1:2484 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5743
Practice Address - Country:US
Practice Address - Phone:561-501-9224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician