Provider Demographics
NPI:1578175451
Name:WOODRICH, KIMBERLY ZOE (BS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ZOE
Last Name:WOODRICH
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0368
Mailing Address - Country:US
Mailing Address - Phone:541-464-6664
Mailing Address - Fax:
Practice Address - Street 1:205 SE JACKSON ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3341
Practice Address - Country:US
Practice Address - Phone:541-464-6664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1366697690Medicaid