Provider Demographics
NPI:1811544588
Name:ELLINGSON, KELLY (MA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ELLINGSON
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16232 BOTHELL EVERETT HWY # 1109
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1520
Mailing Address - Country:US
Mailing Address - Phone:425-522-2555
Mailing Address - Fax:
Practice Address - Street 1:16232 BOTHELL EVERETT HWY # 1109
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1520
Practice Address - Country:US
Practice Address - Phone:425-522-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist