Provider Demographics
NPI:1720370935
Name:REYNOLDS, KIMBERLY GUION (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:GUION
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:E
Other - Last Name:GUION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:707 SW GAINES ST.
Mailing Address - Street 2:CHILD DEVELOPMENT AND REHABILITATION CENTER
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-418-1832
Mailing Address - Fax:503-494-6868
Practice Address - Street 1:707 SW GAINES ST.
Practice Address - Street 2:CDRC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-418-1832
Practice Address - Fax:503-494-6868
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103T00000X
390200000X
OR2149103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program