Provider Demographics
NPI:1568956373
Name:KELLY, ANGELA DIANE (CRM, CACD CANADETE)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:DIANE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRM, CACD CANADETE
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:DIANE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4543
Mailing Address - Country:US
Mailing Address - Phone:541-753-2230
Mailing Address - Fax:
Practice Address - Street 1:306 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4543
Practice Address - Country:US
Practice Address - Phone:541-753-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)