Basic Information
| Provider Information | |||||||||
| NPI: | 1184941445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUNTINGTON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 NE GREENWOOD AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416177365 | ||||||||
| FaxNumber: | 5413126343 | ||||||||
| Practice Location | |||||||||
| Address1: | 461 NE GREENWOOD AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416177365 | ||||||||
| FaxNumber: | 5413126343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2010 | ||||||||
| LastUpdateDate: | 04/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3901428 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 210831 | 05 | OR | MEDICAID |