Provider Demographics
NPI:1528368008
Name:BRUGH, KELLI ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:BRUGH
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 1:356 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-1196
Mailing Address - Country:US
Mailing Address - Phone:541-961-4124
Mailing Address - Fax:855-702-3711
Practice Address - Street 1:530 NW 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3646
Practice Address - Country:US
Practice Address - Phone:541-234-3522
Practice Address - Fax:855-702-3711
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL3967101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500631621Medicaid