Healthcare Provider Details

I. General information

NPI: 1396180808
Provider Name (Legal Business Name): KELLIE M MANN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE STE 300
BOTHELL WA
98021-4418
US

IV. Provider business mailing address

1909 214TH ST SE STE 300
BOTHELL WA
98021-4418
US

V. Phone/Fax

Practice location:
  • Phone: 425-412-7200
  • Fax:
Mailing address:
  • Phone: 425-412-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLH61457270
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: