Provider Demographics
NPI:1013180413
Name:SWANSON, KIMBERLY SHAWN (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHAWN
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 N HIGHWAY 97
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7559
Mailing Address - Country:US
Mailing Address - Phone:541-249-3885
Mailing Address - Fax:541-600-4731
Practice Address - Street 1:2955 N HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:541-249-3885
Practice Address - Fax:541-600-4731
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2185103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2185OtherSTATE LICENSE
OR11827803OtherCAQH ID
OR11827803OtherCAQH ID