Provider Demographics
NPI:1063830289
Name:KELLY, CLIFTON (LMHC)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15408 MAIN ST
Mailing Address - Street 2:#107
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9024
Mailing Address - Country:US
Mailing Address - Phone:206-295-3784
Mailing Address - Fax:
Practice Address - Street 1:15408 MAIN ST
Practice Address - Street 2:#107
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9024
Practice Address - Country:US
Practice Address - Phone:206-295-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60468765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health