Provider Demographics
NPI:1851460885
Name:KOZELISKY, KELLY D (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:D
Last Name:KOZELISKY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6603 220TH ST SW STE 1C
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2186
Mailing Address - Country:US
Mailing Address - Phone:425-776-1056
Mailing Address - Fax:425-776-4357
Practice Address - Street 1:6603 220TH ST SW STE 1C
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2186
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:425-776-4357
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMAOOO12309225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist