Provider Demographics
NPI:1063717320
Name:STRIDER, KELLY RAE (LPC, CADC III)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:STRIDER
Suffix:
Gender:F
Credentials:LPC, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 NE 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-7728
Mailing Address - Country:US
Mailing Address - Phone:503-704-5061
Mailing Address - Fax:
Practice Address - Street 1:4405 NE 34TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-7728
Practice Address - Country:US
Practice Address - Phone:503-704-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2931101YM0800X, 106H00000X
OR10-12-49101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist