1528515434 NPI number — MS. KELLY ANNE HAIDER MS, LPC

Table of content: MS. KELLY ANNE HAIDER MS, LPC (NPI 1528515434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528515434 NPI number — MS. KELLY ANNE HAIDER MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAIDER
Provider First Name:
KELLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
KELLY
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
QMHP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528515434
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6677 14TH AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEIZER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97303-1871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
35-580-0291
Provider Business Mailing Address Fax Number:
503-749-6051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 COMMERCIAL ST NE STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-4078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
35-580-0291
Provider Business Practice Location Address Fax Number:
35-583-2952
Provider Enumeration Date:
09/08/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  R-6443 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: C6923 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122944 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500713541 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: C6923 . This is a "OREGON BOARD OF LICENSED PROFESSIONAL COUNSELORS AND THERAPISTS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".