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NPI Code Detail

MEDICARE: KIMBERLY WALLACE CADC 1

MEDICARE: KIMBERLY WALLACE CADC 1
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor140414OR
2101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1942592340
Entity Type Code : Individual
Provider Name (Legal Business Name) : KIMBERLY WALLACE CADC 1
Provider Business Mailing Address
First Line : 1427 SE 182ND AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97233-5008
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1427 SE 182ND AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97233-5008
Country : US
Telephone Number : 971-202-7851
Fax Number : 503-206-7164
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/04/2011
Last Update Date : 10/04/2018

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Directions to “ KIMBERLY WALLACE CADC 1” Practice Location

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