Provider Demographics
NPI:1841221207
Name:DICKINSON, KELLY A (PH D)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32020 32ND AVE S STE 110
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98001-9349
Mailing Address - Country:US
Mailing Address - Phone:253-838-3090
Mailing Address - Fax:
Practice Address - Street 1:32020 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98001-9349
Practice Address - Country:US
Practice Address - Phone:253-838-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical