Basic Information
| Provider Information | |||||||||
| NPI: | 1225795057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENDERBY | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | QMHA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5240 NE ELAM YOUNG PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971246438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038464555 | ||||||||
| FaxNumber: | 5038463305 | ||||||||
| Practice Location | |||||||||
| Address1: | 5240 NE ELAM YOUNG PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971246438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038464555 | ||||||||
| FaxNumber: | 5038463305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2021 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 21-QMHA-R-1169 | OR | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.