Provider Demographics
NPI:1447130471
Name:KELLY, NICOLE C
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1470 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1366
Mailing Address - Country:US
Mailing Address - Phone:541-316-7520
Mailing Address - Fax:541-504-5505
Practice Address - Street 1:1470 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1366
Practice Address - Country:US
Practice Address - Phone:541-316-7520
Practice Address - Fax:541-504-5505
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)