Provider Demographics
NPI:1134407299
Name:SMITH DALY, KIMBERLEY LYNNE (BC-DMT, CADC-R, LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:LYNNE
Last Name:SMITH DALY
Suffix:
Gender:F
Credentials:BC-DMT, CADC-R, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-571-9240
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-9240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001409225600000X
ORBC-DMT-1131225600000X
ORC5011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC5011OtherOREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS