Healthcare Provider Details

I. General information

NPI: 1467120386
Provider Name (Legal Business Name): ELLINOR KALLSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E OLIVE ST
SEATTLE WA
98122-2735
US

IV. Provider business mailing address

6400 SOUTHCENTER BLVD
TUKWILA WA
98188-2547
US

V. Phone/Fax

Practice location:
  • Phone: 206-302-2212
  • Fax:
Mailing address:
  • Phone: 206-901-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: