Provider Demographics
NPI:1255757837
Name:SWANSTROM SHAW, KELLEY K (MAC, LMHC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:K
Last Name:SWANSTROM SHAW
Suffix:
Gender:F
Credentials:MAC, LMHC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:K
Other - Last Name:SWANSTROM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MAC, LMHC
Mailing Address - Street 1:323 16TH AVE E
Mailing Address - Street 2:104
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5186
Mailing Address - Country:US
Mailing Address - Phone:206-949-4139
Mailing Address - Fax:
Practice Address - Street 1:323 16TH AVE E
Practice Address - Street 2:104
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5186
Practice Address - Country:US
Practice Address - Phone:206-949-4139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011268101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health