Provider Demographics
NPI:1265885065
Name:PETERS, KIMBERLY (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:LCSW
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 85
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0085
Mailing Address - Country:US
Mailing Address - Phone:971-999-0175
Mailing Address - Fax:855-651-0575
Practice Address - Street 1:118 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-8141
Practice Address - Country:US
Practice Address - Phone:971-999-0175
Practice Address - Fax:855-651-0575
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL84921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500712083Medicaid