Provider Demographics
NPI:1417292863
Name:VAN EATON, KIM MARIE (CADC I, CRM, QMHA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:VAN EATON
Suffix:
Gender:F
Credentials:CADC I, CRM, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10920 SW BARBUR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-8600
Mailing Address - Country:US
Mailing Address - Phone:503-244-4500
Mailing Address - Fax:
Practice Address - Street 1:380 NW 6TH AVE
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-7713
Practice Address - Country:US
Practice Address - Phone:877-302-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
ORT-21-1331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker