Provider Demographics
NPI:1538136668
Name:PENGELLY, KIM T (LCSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:T
Last Name:PENGELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 KAEN RD
Mailing Address - Street 2:SUITE 398
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4088
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-655-8350
Practice Address - Street 1:998 LIBRARY CT
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4041
Practice Address - Country:US
Practice Address - Phone:503-655-8401
Practice Address - Fax:503-655-8429
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL26041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK101802Medicare ID - Type Unspecified
ORS10825Medicare UPIN