Provider Demographics
NPI:1609143809
Name:WILLIAMS, KELLY JOANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOANNE
Last Name:WILLIAMS
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-258-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC5020235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist