Healthcare Provider Details

I. General information

NPI: 1356803894
Provider Name (Legal Business Name): KIMBERLIN SANTOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 82ND DR
GLADSTONE OR
97027-1803
US

IV. Provider business mailing address

890 82ND DR
GLADSTONE OR
97027-1803
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-5515
  • Fax: 503-212-2292
Mailing address:
  • Phone: 503-659-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL11626
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

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: