Provider Demographics
NPI:1538843859
Name:FUSCO, KELLIE ANN
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:FUSCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 384
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97462-0384
Mailing Address - Country:US
Mailing Address - Phone:541-680-8396
Mailing Address - Fax:
Practice Address - Street 1:2285 NW STEWART PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5557
Practice Address - Country:US
Practice Address - Phone:541-680-8396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health