Provider Demographics
NPI:1629413448
Name:HUGHES, KEELY KELLY (QMHA, BS)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:KELLY
Last Name:HUGHES
Suffix:
Gender:F
Credentials:QMHA, BS
Other - Prefix:
Other - First Name:KELLON
Other - Middle Name:DONALD
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHA, BS
Mailing Address - Street 1:8770 SW SCOFFINS ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6226
Mailing Address - Country:US
Mailing Address - Phone:503-684-1424
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9695
Practice Address - Country:US
Practice Address - Phone:541-757-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1629413448Medicaid