Provider Demographics
NPI:1891256764
Name:MASSEY, KELLY (LSWAIC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-0001
Mailing Address - Country:US
Mailing Address - Phone:602-574-5466
Mailing Address - Fax:
Practice Address - Street 1:7125 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-0001
Practice Address - Country:US
Practice Address - Phone:602-574-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASWIA.SC.609187891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical