Provider Demographics
NPI:1013557842
Name:KIMBALL, ERICKA (PHD, LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PHD, LCSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 N WILLIAMS AVE APT W214
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2988
Mailing Address - Country:US
Mailing Address - Phone:952-200-2519
Mailing Address - Fax:
Practice Address - Street 1:1800 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5204
Practice Address - Country:US
Practice Address - Phone:503-725-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL79141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical