=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548408206
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI LEA HOLLOWAY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2009
-----------------------------------------------------
Last Update Date | 02/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 SW MACADAM AVENUE SUITE 325
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-295-7900
-----------------------------------------------------
Fax | 503-224-8883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4800 S.W. MACADAM AVENUE SUITE 325
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-295-7900
-----------------------------------------------------
Fax | 503-224-8883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MD23361
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------