Provider Demographics
NPI:1083183370
Name:DEGOEDE, KELLY D (CRM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:DEGOEDE
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 NE 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4268
Mailing Address - Country:US
Mailing Address - Phone:541-306-4446
Mailing Address - Fax:503-550-2011
Practice Address - Street 1:1435 NE 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4268
Practice Address - Country:US
Practice Address - Phone:541-306-4466
Practice Address - Fax:541-550-2011
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-CRM-353175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18-CRM-353Medicaid