MEDICARE: MS. KAREN GAYE KELLY

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	R3372	OR
2	106H00000X	Marriage & Family Therapist	R3372	OR

General Provider Information

NPI Number	:	1982091948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KAREN GAYE KELLY

Provider Business Mailing Address
First Line	:	6206 SE 30TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-8602
Country	:	US
Telephone Number	:	503-765-6221
Fax Number	:

Provider Business Practice Location Address
First Line	:	4431 SE WOODSTOCK BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6271
Country	:	US
Telephone Number	:	503-765-6221
Fax Number	:

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

Provider Enumeration Date	:	04/16/2015
Last Update Date	:	04/16/2015

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