Provider Demographics
NPI:1356835201
Name:KELLY, TANYA MARIE
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 S 62ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-3308
Mailing Address - Country:US
Mailing Address - Phone:253-327-5227
Mailing Address - Fax:
Practice Address - Street 1:8815 S TACOMA WAY STE 122
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-7011
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:253-582-2901
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst