MEDICARE: MS. KELLIE OOSTERBAAN WOLFF

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	103TC0700X	Clinical Psychologist	1642	OR

General Provider Information

NPI Number	:	1982778312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLIE OOSTERBAAN WOLFF

Provider Business Mailing Address
First Line	:	704 COLUMBIA ST
Second Line	:
City	:	HOOD RIVER
State	:	OR
Zip	:	97031-1720
Country	:	US
Telephone Number	:	541-386-6070
Fax Number	:	541-610-1955

Provider Business Practice Location Address
First Line	:	704 COLUMBIA ST
Second Line	:
City	:	HOOD RIVER
State	:	OR
Zip	:	97031-1720
Country	:	US
Telephone Number	:	541-386-6070
Fax Number	:	541-610-1955

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

Provider Enumeration Date	:	11/18/2006
Last Update Date	:	04/29/2015

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