Provider Demographics
NPI:1780913814
Name:KELLEY, SUE (LMT)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NW 3RD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3646
Mailing Address - Country:US
Mailing Address - Phone:541-265-8680
Mailing Address - Fax:541-265-9595
Practice Address - Street 1:530 NW 3RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3646
Practice Address - Country:US
Practice Address - Phone:541-265-8680
Practice Address - Fax:541-265-9595
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-20
Last Update Date:2009-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4443225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist