Provider Demographics
NPI:1902362452
Name:BERRY, KIMBERLY MICHELLE (RBT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20510 SW ROY ROGERS RD UNIT 210
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9320
Mailing Address - Country:US
Mailing Address - Phone:360-771-7538
Mailing Address - Fax:
Practice Address - Street 1:20510 SW ROY ROGERS RD UNIT 210
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9320
Practice Address - Country:US
Practice Address - Phone:360-771-7538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
RBT--19-77656247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORABA-IN-10203849OtherOREGON HEALTH LICENSING
RBT-19-77656OtherBACB