Provider Demographics
NPI:1639411382
Name:SMITH, KRISTIN NICOLE WILKINSON (MED, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE WILKINSON
Last Name:SMITH
Suffix:
Gender:
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 NW 167TH PL STE 115
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4846
Mailing Address - Country:US
Mailing Address - Phone:425-830-6397
Mailing Address - Fax:
Practice Address - Street 1:1800 NW 167TH PL STE 115
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4846
Practice Address - Country:US
Practice Address - Phone:425-830-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA60758885103K00000X
ORABA-B-10253301103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst