Provider Demographics
NPI:1619104338
Name:KELLEY, KIMBERLY MICHELLE (LPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC
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 1225
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1225
Mailing Address - Country:US
Mailing Address - Phone:541-480-3665
Mailing Address - Fax:541-550-3887
Practice Address - Street 1:15 SW COLORADO AVE
Practice Address - Street 2:STE. 130
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1150
Practice Address - Country:US
Practice Address - Phone:541-480-3665
Practice Address - Fax:541-550-3887
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-20
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1101101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional