Provider Demographics
NPI:1720565526
Name:SKILLICORN, KIMBERLY NICOLE (PSYD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:SKILLICORN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 5TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1673
Mailing Address - Country:US
Mailing Address - Phone:831-247-2150
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-331-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2973103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical