Provider Demographics
NPI:1255838017
Name:CARR, KELLIE BRYSON
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BRYSON
Last Name:CARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MICHELLE
Other - Last Name:HUDSPETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:822 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3422
Mailing Address - Country:US
Mailing Address - Phone:623-363-1367
Mailing Address - Fax:
Practice Address - Street 1:711 E MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7139
Practice Address - Country:US
Practice Address - Phone:813-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst