Provider Demographics
NPI:1831800234
Name:FULLER, KIMBERLY KAY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:KAY
Other - Last Name:KAKIUCHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:582 MARKET ST STE 1608
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-5317
Mailing Address - Country:US
Mailing Address - Phone:833-931-1716
Mailing Address - Fax:866-519-5427
Practice Address - Street 1:1020 SW TAYLOR ST STE 560
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2533
Practice Address - Country:US
Practice Address - Phone:541-777-0094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health