Provider Demographics
NPI:1770958399
Name:HARGIS, KIMBERLY J (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:J
Last Name:HARGIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:J
Other - Last Name:HARGIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4455 NE HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-758-5900
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-758-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL75171041C0700X
IL149.0181111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical