MEDICARE: KEILEIGH JOY DULL

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	175T00000X	Peer Specialist	THW2343	OR

General Provider Information

NPI Number	:	1649785817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEILEIGH JOY DULL

Provider Business Mailing Address
First Line	:	3213 CENTER ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-4666
Country	:	US
Telephone Number	:	503-990-3033
Fax Number	:

Provider Business Practice Location Address
First Line	:	3213 CENTER ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-4666
Country	:	US
Telephone Number	:	503-990-3033
Fax Number	:

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

Provider Enumeration Date	:	12/08/2017
Last Update Date	:	12/08/2017

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