Provider Demographics
NPI:1780355651
Name:LELLIS, KATHLEEN ANN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:LELLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE W
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6505 216TH ST SW STE 100
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2089
Practice Address - Country:US
Practice Address - Phone:425-640-7009
Practice Address - Fax:425-678-6455
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123505106H00000X
WAMG61648835106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA123505OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCE