Provider Demographics
NPI:1083998744
Name:COPPERSMITH, KIMBERLY (PSYD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COPPERSMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST STE 855
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2570
Mailing Address - Country:US
Mailing Address - Phone:971-303-9636
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 855
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2570
Practice Address - Country:US
Practice Address - Phone:971-303-9636
Practice Address - Fax:971-200-2425
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2869103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical