Provider Demographics
NPI:1871176685
Name:HANCOCK, KELSEY ELIZABETH (CTRS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELIZABETH
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ELIZABETH
Other - Last Name:AMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 PEARL ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2684
Practice Address - Country:US
Practice Address - Phone:503-657-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR67061225800000X
OR21-QMHA-R-1125171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist