Provider Demographics
NPI:1154945053
Name:SCHIMMELBUSCH, KRISTA LOWE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LOWE
Last Name:SCHIMMELBUSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12540 SW 68TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8597
Mailing Address - Country:US
Mailing Address - Phone:503-914-2880
Mailing Address - Fax:
Practice Address - Street 1:12540 SW 68TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8597
Practice Address - Country:US
Practice Address - Phone:503-914-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6909101YM0800X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program