Provider Demographics
NPI:1669808606
Name:FENIMORE, KELLY MARIE (LMHC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:FENIMORE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 NE 77TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6790
Mailing Address - Country:US
Mailing Address - Phone:360-602-2533
Mailing Address - Fax:360-831-0118
Practice Address - Street 1:4610 NE 77TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6790
Practice Address - Country:US
Practice Address - Phone:360-602-2533
Practice Address - Fax:360-831-0118
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60396096101YA0400X
WACG60417582101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)