Healthcare Provider Details

I. General information

NPI: 1639743669
Provider Name (Legal Business Name): KELLY DIANE WRIGHT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W 8TH AVE
EUGENE OR
97401-2961
US

IV. Provider business mailing address

1741 E 25TH AVE
EUGENE OR
97403-1806
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-8168
  • Fax:
Mailing address:
  • Phone: 541-556-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier05
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: