=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255500203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR KATIE EVANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2008
-----------------------------------------------------
Last Update Date | 10/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19943 SW JETTE LN
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-2789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-756-6117
-----------------------------------------------------
Fax | 503-524-3778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19943 SW JETTE LN
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-2789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-756-6117
-----------------------------------------------------
Fax | 503-524-3778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREATMENT DIRECTOR CEO
-----------------------------------------------------
Name | DR. KATIE EVANS KELLEY
-----------------------------------------------------
Credential | PHD, CDP, RC, NCACII
-----------------------------------------------------
Telephone | 503-756-6117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 860106
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | CP00004591
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------