Provider Demographics
NPI:1780107276
Name:FOWLER, KELLIE DIANA (CBT)
Entity type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:DIANA
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 FAUNTLEROY WAY SW APT N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98136-1557
Mailing Address - Country:US
Mailing Address - Phone:914-419-7140
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST STE 212
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60780423106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician