Provider Demographics
NPI:1699937185
Name:PAYNTER, KELLY NELSON (LCP, ATR-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NELSON
Last Name:PAYNTER
Suffix:
Gender:F
Credentials:LCP, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 SE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5602
Mailing Address - Country:US
Mailing Address - Phone:503-740-4287
Mailing Address - Fax:
Practice Address - Street 1:6615 SE 16TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5602
Practice Address - Country:US
Practice Address - Phone:503-740-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75381101YM0800X
ORC6432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health