Provider Demographics
NPI:1831492040
Name:ELLIOTT, KELLY R (MED, CMHS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MED, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8378 W GRANDRIDGE BLVD STE 110F
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-5402
Mailing Address - Country:US
Mailing Address - Phone:509-392-5091
Mailing Address - Fax:509-315-1295
Practice Address - Street 1:8378 W GRANDRIDGE BLVD STE 110F
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5402
Practice Address - Country:US
Practice Address - Phone:509-392-5091
Practice Address - Fax:509-315-1295
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60325853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health