Provider Demographics
NPI:1710082979
Name:KELLY, TIMOTHY KEVIN (MS)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:KEVIN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4454 NE MASON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1739
Mailing Address - Country:US
Mailing Address - Phone:503-254-7996
Mailing Address - Fax:
Practice Address - Street 1:10163 SE SUNNYSIDE RD STE 490
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5720
Practice Address - Country:US
Practice Address - Phone:503-653-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR C0220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health