=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942618814
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY WINTER LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2014
-----------------------------------------------------
Last Update Date | 01/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 376 SW BLUFF DR STE 2
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-1399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-462-0161
-----------------------------------------------------
Fax | 866-461-6780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2032 NW GREENWOOD PL
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-8813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-972-0096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT106906
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | T1477
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------