Provider Demographics
NPI:1295211001
Name:KELLY, SCOTT EDWARD
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EDWARD
Last Name:KELLY
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 1:967 SW 185TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-6659
Mailing Address - Country:US
Mailing Address - Phone:503-998-1216
Mailing Address - Fax:
Practice Address - Street 1:707 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2922
Practice Address - Country:US
Practice Address - Phone:503-542-4603
Practice Address - Fax:503-233-6093
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty