Provider Demographics
NPI:1982255881
Name:NELSON-DEBRUIN, KELLE
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:
Last Name:NELSON-DEBRUIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2301
Mailing Address - Country:US
Mailing Address - Phone:503-778-0787
Mailing Address - Fax:503-296-2938
Practice Address - Street 1:7320 SW HUNZIKER RD STE 201
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:503-778-0787
Practice Address - Fax:503-296-2938
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ORT1928101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician