Provider Demographics
NPI:1821456559
Name:KELLY, SEAN (CADC I, CRM)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:CADC I, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3715
Mailing Address - Country:US
Mailing Address - Phone:503-335-8611
Mailing Address - Fax:
Practice Address - Street 1:10564 SE WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:971-806-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-008175T00000X
OR20-07-07101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist