Provider Demographics
NPI:1710236757
Name:DOCKERY, KIMBERLEY D (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:D
Last Name:DOCKERY
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-601-3615
Mailing Address - Fax:503-646-1683
Practice Address - Street 1:19250 SW 65TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7707
Practice Address - Country:US
Practice Address - Phone:503-692-1242
Practice Address - Fax:503-691-3615
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9734106H00000X
ORT1550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500705290Medicaid