Basic Information
| Provider Information | |||||||||
| NPI: | 1821456559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC I, CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2318 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033358611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10564 SE WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9718060571 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 08/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 16-CRM-008 | OR | N | 101YA0400X | 20-07-07 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.