Provider Demographics
NPI:1447320833
Name:MARRIOTT, KIMBERLY GAMBLE (PHD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GAMBLE
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 NE SANDY BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5335
Mailing Address - Country:US
Mailing Address - Phone:503-297-2287
Mailing Address - Fax:503-297-1071
Practice Address - Street 1:4036 NE SANDY BLVD
Practice Address - Street 2:STE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5335
Practice Address - Country:US
Practice Address - Phone:503-502-2256
Practice Address - Fax:503-297-1071
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1189103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical