Provider Demographics
NPI:1073836243
Name:TOROK, KELLY (CLC, MT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TOROK
Suffix:
Gender:F
Credentials:CLC, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 257 PMB 6366
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507
Mailing Address - Country:US
Mailing Address - Phone:808-651-6110
Mailing Address - Fax:
Practice Address - Street 1:900 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98507
Practice Address - Country:US
Practice Address - Phone:808-651-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 146N00000X, 225700000X, 374J00000X, 376J00000X
HIALPP#24181163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No376J00000XNursing Service Related ProvidersHomemaker