Provider Demographics
NPI:1013167261
Name:BENNETT-AURDAHL, KELLY KIMBERLY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KIMBERLY
Last Name:BENNETT-AURDAHL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26713 138TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8056
Mailing Address - Country:US
Mailing Address - Phone:206-335-3011
Mailing Address - Fax:
Practice Address - Street 1:26713 138TH PL SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-8056
Practice Address - Country:US
Practice Address - Phone:206-335-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW601604581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980994Medicaid