Healthcare Provider Details

I. General information

NPI: 1376448571
Provider Name (Legal Business Name): KELLY LARSEN QMHP
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 LANCASTER DR NE
SALEM OR
97317
US

IV. Provider business mailing address

569 GREENWOOD DR NE APT 21
KEIZER OR
97303-4655
US

V. Phone/Fax

Practice location:
  • Phone: 971-804-5853
  • Fax:
Mailing address:
  • Phone: 801-548-6341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: