Basic Information
| Provider Information | |||||||||
| NPI: | 1346375037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HYAM | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9700 SW BEAVERTON HILLSDALE HWY | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970053306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036269494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 08/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | R0000WDBCH | 01 | OR | MEDICARE GROUP | OTHER | 164936 | 05 | OR | MEDICAID |