Provider Demographics
NPI:1932522398
Name:KELCH, CHANEL (MA)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:KELCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 STRANDER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2923
Mailing Address - Country:US
Mailing Address - Phone:425-204-1575
Mailing Address - Fax:425-204-8488
Practice Address - Street 1:662 STRANDER BLVD
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2923
Practice Address - Country:US
Practice Address - Phone:425-204-1575
Practice Address - Fax:425-204-8488
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60273541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist