Provider Demographics
NPI:1891008520
Name:FITZPATRICK, P. KELLY (BA, NCAC II, QMHA)
Entity Type:Individual
Prefix:
First Name:P. KELLY
Middle Name:
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:BA, NCAC II, QMHA
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 16756
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0756
Mailing Address - Country:US
Mailing Address - Phone:503-208-2596
Mailing Address - Fax:
Practice Address - Street 1:10570 SE WASHINGTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2846
Practice Address - Country:US
Practice Address - Phone:503-933-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-09-60101YA0400X
OR15-CRM-167175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist