Provider Demographics
NPI:1073015129
Name:ROBISON, KELLY A (LMP)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:A
Last Name:ROBISON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4459 FREMONT AVE NORTH
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103
Mailing Address - Country:US
Mailing Address - Phone:206-501-2092
Mailing Address - Fax:206-708-6638
Practice Address - Street 1:4459 FREMONT AVE NORTH
Practice Address - Street 2:SUITE 2
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103
Practice Address - Country:US
Practice Address - Phone:206-501-2092
Practice Address - Fax:206-708-6638
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60338577225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist