Provider Demographics
NPI:1841708054
Name:HATTERSHIDE STROMBERG, KELLY DAWN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:HATTERSHIDE STROMBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7314 N FISKE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4518
Mailing Address - Country:US
Mailing Address - Phone:503-410-0228
Mailing Address - Fax:
Practice Address - Street 1:1312 SW WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2327
Practice Address - Country:US
Practice Address - Phone:503-535-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)