Healthcare Provider Details

I. General information

NPI: 1548407646
Provider Name (Legal Business Name): MISS KELSEY CORRINE COFFEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2009
Last Update Date: 01/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NE IRVING ST SUITE 250
PORTLAND OR
97232-2243
US

IV. Provider business mailing address

16272 SE LILLIAN CT
MILWAUKIE OR
97267-5344
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-4356
  • Fax:
Mailing address:
  • Phone: 503-381-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: