Provider Demographics
NPI:1295072767
Name:SEAVERT, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SEAVERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:2575 WESTGATE BLDG 1
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-9613
Practice Address - Country:US
Practice Address - Phone:541-429-8721
Practice Address - Fax:541-429-8720
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL46631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000700153OtherBLUE CROSS-SHIELD OF MONTANA
MTM011003003Medicare PIN