Healthcare Provider Details

I. General information

NPI: 1922425123
Provider Name (Legal Business Name): KELLIE ANN HISLOP OTR/L, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE STE 340
ISSAQUAH WA
98029-5449
US

IV. Provider business mailing address

510 8TH AVE NE STE 320
ISSAQUAH WA
98029-5436
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-3051
  • Fax: 425-313-3055
Mailing address:
  • Phone: 425-313-3051
  • Fax: 425-313-3055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT60514402
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60514402
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: