Provider Demographics
NPI:1033511407
Name:PAYNE, KELSEY SMITH (BA, CADC I)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:SMITH
Last Name:PAYNE
Suffix:
Gender:F
Credentials:BA, CADC I
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LYNNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC I
Mailing Address - Street 1:3910 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3241
Mailing Address - Country:US
Mailing Address - Phone:503-206-1059
Mailing Address - Fax:
Practice Address - Street 1:537 SE ALDER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2231
Practice Address - Country:US
Practice Address - Phone:503-206-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-17
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-06-52101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health