Provider Demographics
NPI:1801362322
Name:HENRY, KIMBERLY E
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:3005 NE DIAMOND LAKE BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3609
Practice Address - Country:US
Practice Address - Phone:541-673-3469
Practice Address - Fax:541-266-0874
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health