Basic Information
| Provider Information | |||||||||
| NPI: | 1326405473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | KELSEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST. | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 8184490994 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 SW ROSEWOOD ST. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND (LAKE OSWEGO) | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037832707 | ||||||||
| FaxNumber: | 8184490994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2016 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 10174020 | OR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.