Healthcare Provider Details

I. General information

NPI: 1902340102
Provider Name (Legal Business Name): STEPHEN KELLETT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22659 PACIFIC HWY S SUITE 201
DES MOINES WA
98198-5155
US

IV. Provider business mailing address

22659 PACIFIC HWY S SUITE 201
DES MOINES WA
98198-5155
US

V. Phone/Fax

Practice location:
  • Phone: 206-824-3668
  • Fax:
Mailing address:
  • Phone: 206-824-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60705963
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: