Provider Demographics
NPI:1558590653
Name:WALL, KIMBERLY LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:WALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3638 NE 77TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6406
Mailing Address - Country:US
Mailing Address - Phone:503-449-2951
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1763
Practice Address - Country:US
Practice Address - Phone:503-449-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL33411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical