Provider Demographics
NPI:1790971695
Name:WITHERELL, KERRY LAUREN (AUD)
Entity Type:Individual
Prefix:MISS
First Name:KERRY
Middle Name:LAUREN
Last Name:WITHERELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 9TH AVE
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-583-6025
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-8802
Practice Address - Fax:206-515-5886
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00004703231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8501983Medicaid
WA8719WIOtherBLUE SHIELD #
WAP00444843OtherRAILROAD MC #
WA8501983Medicaid