Healthcare Provider Details

I. General information

NPI: 1760653877
Provider Name (Legal Business Name): NATHAN KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STONEWOOD DR
EUGENE OR
97405-3559
US

IV. Provider business mailing address

417 STONEWOOD DR
EUGENE OR
97405-3559
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-9226
  • Fax:
Mailing address:
  • Phone: 541-686-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
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: