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General NPI Number Information
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NPI Number | 1720565526
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Entity Type | Individual
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Provider Name | KIMBERLY NICOLE SKILLICORN PSYD
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Gender | Female
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Dates
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Enumeration Date | 07/24/2018
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Last Update Date | 12/17/2021
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Provider Practice Location Address
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Address Line | 3550 N INTERSTATE AVE
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City | PORTLAND
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State | OR
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Zip | 97227-1196
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Country | US
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Telephone | 503-331-6357
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Fax |
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Provider Business Mailing Address
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Address Line | 2309 5TH AVE APT 404
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City | SAN DIEGO
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State | CA
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Zip | 92101-1673
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Country | US
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Telephone | 831-247-2150
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2973
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License Number State | OR
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