Provider Demographics
NPI:1437404779
Name:KELLY, MEGAN CLARE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CLARE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 LEARY AVE NW
Mailing Address - Street 2:APT 646
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4081
Mailing Address - Country:US
Mailing Address - Phone:360-331-0141
Mailing Address - Fax:360-331-0142
Practice Address - Street 1:5575 N HARBOR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FREELAND
Practice Address - State:WA
Practice Address - Zip Code:98249
Practice Address - Country:US
Practice Address - Phone:360-331-0141
Practice Address - Fax:360-331-0142
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0011799225100000X
AZ10222225100000X
WAPT60482651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038329Medicaid
WA328951OtherWA L&I
WA328951OtherWA L&I