Provider Demographics
NPI:1821653221
Name:MCKELVIN, QUIANA LATRICE
Entity Type:Individual
Prefix:
First Name:QUIANA
Middle Name:LATRICE
Last Name:MCKELVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:QUIANA
Other - Middle Name:LATRICE
Other - Last Name:BROUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3857 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5268
Mailing Address - Country:US
Mailing Address - Phone:360-704-7170
Mailing Address - Fax:
Practice Address - Street 1:3857 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5268
Practice Address - Country:US
Practice Address - Phone:360-704-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60955454101Y00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor