MEDICARE: KYRAI IVY ANN ROSE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1831704071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYRAI IVY ANN ROSE PH.D.

Provider Business Mailing Address
First Line	:	1075 MONEDA AVE N
Second Line	:
City	:	KEIZER
State	:	OR
Zip	:	97303-6256
Country	:	US
Telephone Number	:	859-200-8013
Fax Number	:	541-314-9444

Provider Business Practice Location Address
First Line	:	147 COMMERCIAL ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3416
Country	:	US
Telephone Number	:	541-204-6292
Fax Number	:	541-314-9444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2020
Last Update Date	:	04/25/2025

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