MEDICARE: DR. KELLI LEA HOLLOWAY M.D.

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	MD23361	OR

General Provider Information

NPI Number	:	1548408206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLI LEA HOLLOWAY M.D.

Provider Business Mailing Address
First Line	:	4800 S.W. MACADAM AVENUE
Second Line	:	SUITE 325
City	:	PORTLAND
State	:	OR
Zip	:	97239-3927
Country	:	US
Telephone Number	:	503-295-7900
Fax Number	:	503-224-8883

Provider Business Practice Location Address
First Line	:	4800 SW MACADAM AVENUE
Second Line	:	SUITE 325
City	:	PORTLAND
State	:	OR
Zip	:	97239-3927
Country	:	US
Telephone Number	:	503-295-7900
Fax Number	:	503-224-8883

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

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	02/03/2009

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