Healthcare Provider Details

I. General information

NPI: 1861620700
Provider Name (Legal Business Name): KELLIE J ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 07/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 82ND DR BLDG C
GLADSTONE OR
97027-1803
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-5515
  • Fax: 503-594-8193
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: