Provider Demographics
NPI:1366142564
Name:KETOLA, LELANIA
Entity type:Individual
Prefix:
First Name:LELANIA
Middle Name:
Last Name:KETOLA
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 1:4400 SALEM DALLAS HWY NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3338
Mailing Address - Country:US
Mailing Address - Phone:503-991-5091
Mailing Address - Fax:503-990-6828
Practice Address - Street 1:4400 SALEM DALLAS HWY NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3338
Practice Address - Country:US
Practice Address - Phone:503-991-5091
Practice Address - Fax:503-990-6828
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA373213H101YS0200X
OR521303101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool