Provider Demographics
NPI:1689228751
Name:BROWN, KIMBERLY ANNE (CADC II , QMHA-R)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:CADC II , QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 CHESHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5060
Mailing Address - Country:US
Mailing Address - Phone:541-684-4100
Mailing Address - Fax:541-684-4156
Practice Address - Street 1:687 CHESHIRE AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402
Practice Address - Country:US
Practice Address - Phone:541-684-4100
Practice Address - Fax:541-684-4156
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-27
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-QMHA-R-0164101YM0800X
OR19-R-20101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19-R-20Medicaid