Provider Demographics
NPI:1942592340
Name:WALLACE, KIMBERLY (CADC 1)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 SE 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1427 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5008
Practice Address - Country:US
Practice Address - Phone:971-202-7851
Practice Address - Fax:503-206-7164
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140414101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)