Healthcare Provider Details

I. General information

NPI: 1295072767
Provider Name (Legal Business Name): KIMBERLY SEAVERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 07/31/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 WESTGATE BLDG 1
PENDLETON OR
97801-9613
US

IV. Provider business mailing address

3587 HEATHROW WAY
MEDFORD OR
97504-4004
US

V. Phone/Fax

Practice location:
  • Phone: 541-429-8721
  • Fax: 541-429-8720
Mailing address:
  • Phone: 541-858-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4663
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: