Basic Information
| Provider Information | |||||||||
| NPI: | 1578113791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OVESON | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5416082888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2019 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 20-QMHP-R-0077 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.