Provider Demographics
NPI:1497832026
Name:KISAMORE, KIMBERLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KISAMORE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 EDGEWATER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4049
Mailing Address - Country:US
Mailing Address - Phone:503-588-5816
Mailing Address - Fax:503-588-5803
Practice Address - Street 1:1245 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-588-5816
Practice Address - Fax:503-588-5803
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT39363106H00000X
ORT0562106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist