Healthcare Provider Details

I. General information

NPI: 1184013161
Provider Name (Legal Business Name): KEEP ON DANCING MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 COLBY AVE STE 328
EVERETT WA
98201
US

IV. Provider business mailing address

2722 COLBY AVE SUITE 328
EVERETT WA
98201-3557
US

V. Phone/Fax

Practice location:
  • Phone: 425-740-3600
  • Fax: 425-740-3601
Mailing address:
  • Phone: 425-740-3600
  • Fax: 425-740-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP30007518
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW00009392
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLW00009392
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW00009392
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00009392
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00059378
License Number StateWA

VIII. Authorized Official

Name: DESSETTA L SMITH
Title or Position: BILLING/OFFICE MNGR., AUTH. OFFICIA
Credential:
Phone: 425-740-3600