Healthcare Provider Details

I. General information

NPI: 1811304330
Provider Name (Legal Business Name): KELSE-MARIA LANDIS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BOND ST
ASTORIA OR
97103-6009
US

IV. Provider business mailing address

65 N HIGHWAY 101 STE 204
WARRENTON OR
97146-9371
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-5722
  • Fax:
Mailing address:
  • Phone: 503-325-5722
  • Fax: 503-861-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: