Provider Demographics
NPI:1861890634
Name:DICKINSON, KELLIE JO
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JO
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:702 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3121
Mailing Address - Country:US
Mailing Address - Phone:541-889-9167
Mailing Address - Fax:541-889-7873
Practice Address - Street 1:702 SUNSET DR
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3121
Practice Address - Country:US
Practice Address - Phone:541-889-9167
Practice Address - Fax:541-889-7873
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)