Provider Demographics
NPI:1265022131
Name:MCDILL, KIMBERLY CAROL
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CAROL
Last Name:MCDILL
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 1:15532 SW PACIFIC HWY # 215
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3598
Mailing Address - Country:US
Mailing Address - Phone:503-686-8574
Mailing Address - Fax:
Practice Address - Street 1:9630 SW OMARA ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4929
Practice Address - Country:US
Practice Address - Phone:035-686-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6342101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor