Individual
KIMBERLY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CADC 1
Contact information
Practice address
1427 SE 182ND AVE, PORTLAND, OR 97233-5008
(971) 202-7851
(503) 206-7164
Mailing address
1427 SE 182ND AVE, PORTLAND, OR 97233-5008
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
140414
OR
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Enumeration date
05/04/2011
Last updated
10/04/2018
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