Provider Demographics
NPI:1437289394
Name:GOLLETZ, KIMBERLEY WOLK (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:WOLK
Last Name:GOLLETZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2136
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2136
Mailing Address - Country:US
Mailing Address - Phone:541-758-1556
Mailing Address - Fax:
Practice Address - Street 1:1300 NW HARRISON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6277
Practice Address - Country:US
Practice Address - Phone:541-758-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1155103TC0700X
WA1542103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical