=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225795057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY ENDERBY QMHA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2021
-----------------------------------------------------
Last Update Date | 11/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5240 NE ELAM YOUNG PKWY STE 100
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97124-6438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-846-4555
-----------------------------------------------------
Fax | 503-846-3305
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5240 NE ELAM YOUNG PKWY STE 100
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97124-6438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-846-4555
-----------------------------------------------------
Fax | 503-846-3305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 21-QMHA-R-1169
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------