Healthcare Provider Details

I. General information

NPI: 1063142131
Provider Name (Legal Business Name): KELLY RUBENACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 AUBURN WAY N
AUBURN WA
98002-1311
US

IV. Provider business mailing address

6400 SOUTHCENTER BLVD
TUKWILA WA
98188-2547
US

V. Phone/Fax

Practice location:
  • Phone: 206-251-8237
  • Fax:
Mailing address:
  • Phone: 206-251-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number70141287
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: