Provider Demographics
NPI:1114265840
Name:COLLINS, KELLIE L
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 SW CEDAR HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1342
Mailing Address - Country:US
Mailing Address - Phone:503-352-6000
Mailing Address - Fax:503-352-6080
Practice Address - Street 1:2935 SW CEDAR HILLS BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1342
Practice Address - Country:US
Practice Address - Phone:503-352-6000
Practice Address - Fax:503-352-6080
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR2813101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health