Provider Demographics
NPI:1669991212
Name:RANDALL, KIMBERLY JAYE (CADC, CRM)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JAYE
Last Name:RANDALL
Suffix:
Gender:F
Credentials:CADC, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5442
Mailing Address - Country:US
Mailing Address - Phone:503-645-3581
Mailing Address - Fax:503-629-8517
Practice Address - Street 1:1030 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:503-239-8406
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW1868175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW1868Medicaid