Provider Demographics
NPI:1639743669
Name:WRIGHT, KELLY DIANE (MSW, QMHP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MSW, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 TENNYSON AVE APT 162
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-7604
Mailing Address - Country:US
Mailing Address - Phone:541-556-9089
Mailing Address - Fax:
Practice Address - Street 1:2650 SUZANNE WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7319
Practice Address - Country:US
Practice Address - Phone:541-228-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR05Medicaid