Healthcare Provider Details

I. General information

NPI: 1972947596
Provider Name (Legal Business Name): LINDA J KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 NE PURCELL BLVD
BEND OR
97701-6022
US

IV. Provider business mailing address

PO BOX 5579
BEND OR
97708-5579
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-2700
  • Fax: 541-516-3877
Mailing address:
  • Phone: 541-706-2700
  • Fax: 541-516-3877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL321
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: