Provider Demographics
NPI:1669516605
Name:MCINTOSH, KELLI LORAY (LDM, CPM)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LORAY
Last Name:MCINTOSH
Suffix:
Gender:
Credentials:LDM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15025 NE ROSE PKWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4522
Mailing Address - Country:US
Mailing Address - Phone:503-329-4107
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 90309
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97290-0309
Practice Address - Country:US
Practice Address - Phone:503-549-4714
Practice Address - Fax:503-506-0441
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL116791041C0700X
ORDEM-LD-10112926176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwife
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty