Basic Information
| Provider Information | |||||||||
| NPI: | 1912143694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUGTIV - ELLIOTT | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ANNMARIE | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | ELLIOTT | ||||||||
| OtherFirstName: | KELLIE | ||||||||
| OtherMiddleName: | ANNMARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 49818 MCKENZIE HWY | ||||||||
| Address2: | |||||||||
| City: | VIDA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974889743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418221196 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1790 W 11TH | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416861262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 12/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.