Provider Demographics
NPI:1649099540
Name:BATES, KELLY (CRM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 BIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6178
Mailing Address - Country:US
Mailing Address - Phone:541-690-1995
Mailing Address - Fax:541-749-2126
Practice Address - Street 1:750 BIDDLE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6178
Practice Address - Country:US
Practice Address - Phone:541-690-1995
Practice Address - Fax:541-749-2126
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-CRM-3330101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)