Provider Demographics
NPI:1205989886
Name:ROSS, KELLY L (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E MADISON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-4865
Mailing Address - Country:US
Mailing Address - Phone:206-723-3402
Mailing Address - Fax:
Practice Address - Street 1:2800 E MADISON ST STE 203
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-4865
Practice Address - Country:US
Practice Address - Phone:206-723-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00008901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health