Provider Demographics
NPI:1013424407
Name:BROWN, KELLY KRISTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KRISTON
Last Name:BROWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 CHESTNUT DR W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-1522
Mailing Address - Country:US
Mailing Address - Phone:253-503-6226
Mailing Address - Fax:
Practice Address - Street 1:4004 CHESTNUT DR W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-1522
Practice Address - Country:US
Practice Address - Phone:253-503-6226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-07
Last Update Date:2018-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60236263103T00000X, 103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical