Healthcare Provider Details

I. General information

NPI: 1578040754
Provider Name (Legal Business Name): MICHELLE B KENNEDY CRM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HAILEY AVE STE 204
PENDLETON OR
97801-3072
US

IV. Provider business mailing address

PO BOX 882
PENDLETON OR
97801-0882
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-4104
  • Fax:
Mailing address:
  • Phone: 541-663-4104
  • Fax: 541-663-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-08-20624
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number16-CRM-012
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QMHA-R-7080
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: