Provider Demographics
NPI:1699320440
Name:BENNETT, KELLI DIANE
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:DIANE
Last Name:BENNETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SW 4TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-9629
Mailing Address - Country:US
Mailing Address - Phone:541-475-6575
Mailing Address - Fax:
Practice Address - Street 1:850 SW 4TH ST STE 302
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-9629
Practice Address - Country:US
Practice Address - Phone:541-475-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health