Provider Demographics
NPI:1548408206
Name:HOLLOWAY, KELLI LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:LEA
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 S.W. MACADAM AVENUE
Mailing Address - Street 2:SUITE 325
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3927
Mailing Address - Country:US
Mailing Address - Phone:503-295-7900
Mailing Address - Fax:503-224-8883
Practice Address - Street 1:4800 SW MACADAM AVENUE
Practice Address - Street 2:SUITE 325
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3927
Practice Address - Country:US
Practice Address - Phone:503-295-7900
Practice Address - Fax:503-224-8883
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23361101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional