Healthcare Provider Details

I. General information

NPI: 1215345681
Provider Name (Legal Business Name): CLINTON E KITTRELL MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46314 TIMINE WAY
PENDLETON OR
97801-9099
US

IV. Provider business mailing address

46314 TIMINE WAY
PENDLETON OR
97801-9099
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax: 541-240-8410
Mailing address:
  • Phone: 541-966-9830
  • Fax: 541-240-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberL6482
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: