Provider Demographics
NPI:1790272508
Name:MILLS, KELLY ANNETTE (CDP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNETTE
Last Name:MILLS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 SUNFLOWER LN SW APT 20-202
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-0440
Mailing Address - Country:US
Mailing Address - Phone:360-790-7533
Mailing Address - Fax:
Practice Address - Street 1:6005 TYEE DR SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7356
Practice Address - Country:US
Practice Address - Phone:360-464-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60562513101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)