Provider Demographics
NPI:1104408871
Name:WARD, KELLIE (MS, LPC INTERN)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:MS, LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 SCHOOLHOUSE CT NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3292
Mailing Address - Country:US
Mailing Address - Phone:541-760-1033
Mailing Address - Fax:
Practice Address - Street 1:272 NW MEDICAL LOOP STE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5597
Practice Address - Country:US
Practice Address - Phone:541-900-4285
Practice Address - Fax:888-810-2993
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6803101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor