Provider Demographics
NPI:1417356759
Name:KELSEY SCAMPOLI
Entity Type:Organization
Organization Name:KELSEY SCAMPOLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCAMPOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-386-5611
Mailing Address - Street 1:5019 GROVE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4491
Mailing Address - Country:US
Mailing Address - Phone:360-386-5611
Mailing Address - Fax:
Practice Address - Street 1:5019 GROVE ST STE 103A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4487
Practice Address - Country:US
Practice Address - Phone:360-386-5611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60435605101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty