Healthcare Provider Details

I. General information

NPI: 1538460266
Provider Name (Legal Business Name): KELLY RUTH GROVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10011 SE DIVISION ST STE 202
PORTLAND OR
97266-1353
US

IV. Provider business mailing address

399 E 10TH AVE
EUGENE OR
97401-3380
US

V. Phone/Fax

Practice location:
  • Phone: 503-928-3998
  • Fax: 541-868-2003
Mailing address:
  • Phone: 541-868-2004
  • Fax: 541-868-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4298
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: