Healthcare Provider Details

I. General information

NPI: 1700394558
Provider Name (Legal Business Name): KEVIN KELLEY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 COUNTRY CLUB RD STE 100
EUGENE OR
97401-6039
US

IV. Provider business mailing address

921 COUNTRY CLUB RD STE 100
EUGENE OR
97401-6039
US

V. Phone/Fax

Practice location:
  • Phone: 541-510-5071
  • Fax:
Mailing address:
  • Phone: 541-510-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC5590
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: