Provider Demographics
NPI:1891251286
Name:KELLY, ROBERT (MA, CADC-I)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA, CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 SW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-4152
Mailing Address - Country:US
Mailing Address - Phone:503-848-5861
Mailing Address - Fax:503-848-5863
Practice Address - Street 1:178 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4152
Practice Address - Country:US
Practice Address - Phone:503-416-4547
Practice Address - Fax:503-416-4553
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500764578Medicaid