Provider Demographics
NPI:1568718625
Name:SAMUELS, KELSEY I (LMP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:I
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16810 108TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5413
Mailing Address - Country:US
Mailing Address - Phone:425-227-0111
Mailing Address - Fax:425-228-2583
Practice Address - Street 1:16810 108TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5413
Practice Address - Country:US
Practice Address - Phone:425-227-0111
Practice Address - Fax:425-228-2583
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60280950225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist