Provider Demographics
NPI:1639211725
Name:FLEMETAKIS, KELLY TODD (MOT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TODD
Last Name:FLEMETAKIS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16635 168TH PL NE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8988
Mailing Address - Country:US
Mailing Address - Phone:206-683-4928
Mailing Address - Fax:425-481-3332
Practice Address - Street 1:16635 168TH PL NE
Practice Address - Street 2:SUITE 2
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8988
Practice Address - Country:US
Practice Address - Phone:206-683-4928
Practice Address - Fax:425-481-3332
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003368225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3153FLOtherREGENCE PROVIDER NUMBER
WA351452100000OtherPREMERA PROVIDER NUMBER
WA743167413OtherTAX IDENTIFICATION NUMBER
WA7683683Medicaid
WA0007633803OtherAETNA PROVIDER NUMBER