Provider Demographics
NPI:1336578665
Name:WISOTZKE, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WISOTZKE
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 1:5440 SW WESTGATE DR
Mailing Address - Street 2:STE 175
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2420
Mailing Address - Country:US
Mailing Address - Phone:971-231-5519
Mailing Address - Fax:
Practice Address - Street 1:5440 SW WESTGATE DR
Practice Address - Street 2:STE 175
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2420
Practice Address - Country:US
Practice Address - Phone:971-231-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral