Provider Demographics
NPI:1821462151
Name:WASHINGTON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WASHINGTON
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 1:407 AVENUE G APT 31
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5920
Mailing Address - Country:US
Mailing Address - Phone:801-200-5537
Mailing Address - Fax:
Practice Address - Street 1:407 AVENUE G APT 31
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5920
Practice Address - Country:US
Practice Address - Phone:801-200-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9570922-6004101YM0800X
UT9570922-6009101YM0800X
CA5941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health