Healthcare Provider Details

I. General information

NPI: 1285538751
Provider Name (Legal Business Name): KIMBERLY J KIMNACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 SW MARKET ST APT 1109
PORTLAND OR
97201-3509
US

IV. Provider business mailing address

1177 SW MARKET ST APT 1109
PORTLAND OR
97201-3509
US

V. Phone/Fax

Practice location:
  • Phone: 971-352-1273
  • Fax:
Mailing address:
  • Phone: 971-352-1273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-255709
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: