MEDICARE: KELLY RUTH GROVER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4298	OR

General Provider Information

NPI Number	:	1538460266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RUTH GROVER

Provider Business Mailing Address
First Line	:	399 E 10TH AVE
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-3380
Country	:	US
Telephone Number	:	541-868-2004
Fax Number	:	541-868-2003

Provider Business Practice Location Address
First Line	:	10011 SE DIVISION ST STE 202
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97266-1353
Country	:	US
Telephone Number	:	503-928-3998
Fax Number	:	541-868-2003

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2010
Last Update Date	:	05/04/2022

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