Healthcare Provider Details

I. General information

NPI: 1235721820
Provider Name (Legal Business Name): KELLY ARLYNNE ROWLETT QMHA-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 BIRCH AVE
COTTAGE GROVE OR
97424-1413
US

IV. Provider business mailing address

PO BOX 5
COTTAGE GROVE OR
97424-0001
US

V. Phone/Fax

Practice location:
  • Phone: 541-767-4188
  • Fax: 541-942-9310
Mailing address:
  • Phone: 541-767-4188
  • Fax: 541-942-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: