Provider Demographics
NPI:1649748492
Name:LOVELACE, KELLEY MARIE (CO60564008)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:MARIE
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:CO60564008
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 WHEATON WAY STE F
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3500
Mailing Address - Country:US
Mailing Address - Phone:360-876-9430
Mailing Address - Fax:
Practice Address - Street 1:4060 WHEATON WAY STE F
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3500
Practice Address - Country:US
Practice Address - Phone:360-876-9430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60564008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)