Provider Demographics
NPI:1184941445
Name:HUNTINGTON, KELLI (CADC-I)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:HUNTINGTON
Suffix:
Gender:F
Credentials:CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 NE GREENWOOD AVE
Mailing Address - Street 2:STE A
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4607
Mailing Address - Country:US
Mailing Address - Phone:541-617-7365
Mailing Address - Fax:541-312-6343
Practice Address - Street 1:461 NE GREENWOOD AVE
Practice Address - Street 2:STE A
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4607
Practice Address - Country:US
Practice Address - Phone:541-617-7365
Practice Address - Fax:541-312-6343
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3901428101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210831Medicaid