Provider Demographics
NPI:1508166919
Name:MEDEIROS-WHEELER, KELLY JO (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JO
Last Name:MEDEIROS-WHEELER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:2251 E HANCOCK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2145
Practice Address - Country:US
Practice Address - Phone:971-281-3000
Practice Address - Fax:503-357-4371
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL44161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500658417Medicaid
OR500658417Medicaid