Basic Information
Provider Information | |||||||||
NPI: | 1710016563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALUSOVA | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | JOANNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERSON | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | JOANNE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS, LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 58646 MCNULTY WAY | ||||||||
Address2: |   | ||||||||
City: | SAINT HELENS | ||||||||
State: | OR | ||||||||
PostalCode: | 970516210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033975211 | ||||||||
FaxNumber: | 5033975373 | ||||||||
Practice Location | |||||||||
Address1: | 5240 NE ELAM YOUNG PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | HILLSBORO | ||||||||
State: | OR | ||||||||
PostalCode: | 97124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5038464555 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2007 | ||||||||
LastUpdateDate: | 06/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C1743 | OR | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.