Provider Demographics
NPI:1942745237
Name:KELLY, KATHERINE A
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:E
Other - Last Name:EMARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10330 SE 32ND AVE
Mailing Address - Street 2:320
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE
Practice Address - Street 2:320
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6587
Practice Address - Country:US
Practice Address - Phone:503-513-8693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR30871231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist