Provider Demographics
NPI:1528515434
Name:HAIDER, KELLY ANNE (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:HAIDER
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHP
Mailing Address - Street 1:6677 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-1871
Mailing Address - Country:US
Mailing Address - Phone:035-580-0291
Mailing Address - Fax:503-749-6051
Practice Address - Street 1:223 COMMERCIAL ST NE STE 206
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4078
Practice Address - Country:US
Practice Address - Phone:035-580-0291
Practice Address - Fax:035-583-2952
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR-6443101YM0800X
104100000X
ORC6923101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122944Medicaid
OR500713541Medicaid
ORC6923OtherOREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS