Basic Information
| Provider Information | |||||||||
| NPI: | 1689228751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADC II , QMHA-R | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416844100 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Practice Location | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416844100 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2019 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 20-QMHA-R-0164 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 19-R-20 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 19-R-20 | 05 | OR | MEDICAID |