Provider Demographics
NPI:1962724534
Name:KIMMELL, SHIRLEY J (MS, LPC)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:J
Last Name:KIMMELL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NE 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1527
Mailing Address - Country:US
Mailing Address - Phone:503-287-5793
Mailing Address - Fax:
Practice Address - Street 1:1730 NE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1527
Practice Address - Country:US
Practice Address - Phone:503-287-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0603101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional