Provider Demographics
NPI:1457019549
Name:MCKELVEY, RICHARD DONOVAN (SUDPT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DONOVAN
Last Name:MCKELVEY
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2304
Mailing Address - Country:US
Mailing Address - Phone:206-464-1570
Mailing Address - Fax:
Practice Address - Street 1:1811 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1403
Practice Address - Country:US
Practice Address - Phone:206-464-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60962314390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program