Provider Demographics
NPI:1609940030
Name:KELLIE OOSTERBAAN PSYD RD PC
Entity Type:Organization
Organization Name:KELLIE OOSTERBAAN PSYD RD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OOSTERBAAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD RD
Authorized Official - Phone:541-788-5744
Mailing Address - Street 1:704 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-1720
Mailing Address - Country:US
Mailing Address - Phone:541-788-5744
Mailing Address - Fax:541-610-1955
Practice Address - Street 1:1100 E MARINA WAY STE 221
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2353
Practice Address - Country:US
Practice Address - Phone:541-386-6070
Practice Address - Fax:541-610-1955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty