Provider Demographics
NPI:1346737327
Name:KELLEY, LINDY DAWN
Entity Type:Individual
Prefix:
First Name:LINDY
Middle Name:DAWN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDY
Other - Middle Name:DAWN
Other - Last Name:ENSIGN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, CAAR
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:1616 10TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-5086
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60847186101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2101454Medicaid