Provider Demographics
NPI:1063008415
Name:EDENS, KELLY ELIZABETH (BS)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:EDENS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11860 SW QUEEN ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2634
Mailing Address - Country:US
Mailing Address - Phone:503-537-7588
Mailing Address - Fax:
Practice Address - Street 1:11860 SW QUEEN ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2634
Practice Address - Country:US
Practice Address - Phone:503-537-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor