Provider Demographics
NPI:1871197814
Name:MOFFETT, KEONNA (LICSW)
Entity Type:Individual
Prefix:
First Name:KEONNA
Middle Name:
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 S 122ND ST
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98178-3437
Mailing Address - Country:US
Mailing Address - Phone:206-725-0924
Mailing Address - Fax:
Practice Address - Street 1:2715 NACHES AVE SW
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2627
Practice Address - Country:US
Practice Address - Phone:206-630-1680
Practice Address - Fax:206-630-1601
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW606087151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical