Healthcare Provider Details

I. General information

NPI: 1316470446
Provider Name (Legal Business Name): KIMBERLY LAUREN GILL MSW, LCSW, LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 CHAD DR
EUGENE OR
97408-7428
US

IV. Provider business mailing address

3355 CHAD DR
EUGENE OR
97408-7428
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7836
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6194
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17216
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: