Provider Demographics
NPI:1912143694
Name:RUGTIV - ELLIOTT, KELLIE ANNMARIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANNMARIE
Last Name:RUGTIV - ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ANNMARIE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:49818 MCKENZIE HWY
Mailing Address - Street 2:
Mailing Address - City:VIDA
Mailing Address - State:OR
Mailing Address - Zip Code:97488-9743
Mailing Address - Country:US
Mailing Address - Phone:541-822-1196
Mailing Address - Fax:
Practice Address - Street 1:1790 W 11TH
Practice Address - Street 2:SUITE 290
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402
Practice Address - Country:US
Practice Address - Phone:541-686-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health