Provider Demographics
NPI:1437519261
Name:KELLY, JULIENNE
Entity Type:Individual
Prefix:
First Name:JULIENNE
Middle Name:
Last Name:KELLY
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 1:318 NE ROBERTS AVE
Mailing Address - Street 2:301
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7477
Mailing Address - Country:US
Mailing Address - Phone:720-308-5463
Mailing Address - Fax:
Practice Address - Street 1:318 NE ROBERTS AVE
Practice Address - Street 2:301
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7477
Practice Address - Country:US
Practice Address - Phone:720-308-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health