Provider Demographics
NPI:1093110116
Name:KELTY, MICHAEL B
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:KELTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD STE 300N
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5703
Mailing Address - Country:US
Mailing Address - Phone:281-286-2999
Mailing Address - Fax:512-607-4893
Practice Address - Street 1:3975 RIVER RD N STE 1
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4811
Practice Address - Country:US
Practice Address - Phone:503-676-5631
Practice Address - Fax:503-676-5617
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237600000X
ORHASP761619237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter