Healthcare Provider Details

I. General information

NPI: 1164468310
Provider Name (Legal Business Name): SHARON L KELLY LPA, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST SUITE 420
EUGENE OR
97401-8122
US

IV. Provider business mailing address

PO BOX 24410
EUGENE OR
97402-0451
US

V. Phone/Fax

Practice location:
  • Phone: 541-744-0828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5029
License Number StateOR

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: