Provider Demographics
NPI:1114464336
Name:STENSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 DIVISION ST
Mailing Address - Street 2:#B
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-8014
Mailing Address - Country:US
Mailing Address - Phone:360-676-2020
Mailing Address - Fax:360-734-2106
Practice Address - Street 1:2030 DIVISION ST
Practice Address - Street 2:#B
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8014
Practice Address - Country:US
Practice Address - Phone:360-676-2020
Practice Address - Fax:360-734-2106
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60895861101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)