Healthcare Provider Details

I. General information

NPI: 1003376195
Provider Name (Legal Business Name): KELLI ALEXANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SIMPSON AVE STE 101
ABERDEEN WA
98520-4333
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-612-0012
  • Fax: 360-532-0670
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number60881285
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: