Provider Demographics
NPI:1659846319
Name:BRUSOE, KELLEY JEAN
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JEAN
Last Name:BRUSOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 148TH ST SW APT C101
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-5537
Mailing Address - Country:US
Mailing Address - Phone:920-530-7189
Mailing Address - Fax:
Practice Address - Street 1:1210 SW 136TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1214
Practice Address - Country:US
Practice Address - Phone:206-257-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60571280101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)