MEDICARE: KELLY PAMELA CACERES LPC

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	C7778	OR

General Provider Information

NPI Number	:	1992570956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY PAMELA CACERES LPC

Provider Business Mailing Address
First Line	:	4121 COBB WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-6560
Country	:	US
Telephone Number	:	503-896-2664
Fax Number	:

Provider Business Practice Location Address
First Line	:	4121 COBB WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-6560
Country	:	US
Telephone Number	:	503-896-2664
Fax Number	:

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

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	11/20/2023

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