MEDICARE: KELLY DAWN HATTERSHIDE

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	101YM0800X	Mental Health Counselor	19-QMHA-1-01054	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	19-12-22	OR

General Provider Information

NPI Number	:	1841708054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DAWN HATTERSHIDE

Provider Business Mailing Address
First Line	:	34575 NOBLE RD
Second Line	:
City	:	SAINT HELENS
State	:	OR
Zip	:	97051-9332
Country	:	US
Telephone Number	:	503-396-3848
Fax Number	:

Provider Business Practice Location Address
First Line	:	7931 NE HALSEY ST STE 200
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-6755
Country	:	US
Telephone Number	:	971-803-0138
Fax Number	:	971-352-1088

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

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	12/18/2025

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