Provider Demographics
NPI:1467184317
Name:TOBAR, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:TOBAR
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 1:510 E MAIN STE H
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-5613
Mailing Address - Country:US
Mailing Address - Phone:253-848-3891
Mailing Address - Fax:
Practice Address - Street 1:510 E MAIN STE H
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-5613
Practice Address - Country:US
Practice Address - Phone:253-848-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61253045104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker