Individual
KIMBERLY JAYE RANDALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CADC, CRM
Contact information
Practice address
1030 NE COUCH ST, PORTLAND, OR 97232
(503) 239-8400
(503) 239-8406
Mailing address
14600 NW CORNELL RD, PORTLAND, OR 97229-5442
(503) 645-3581
(503) 629-8517
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
THW1868
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
THW1868
—
OR
Enumeration date
09/14/2017
Last updated
08/31/2023
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