Healthcare Provider Details

I. General information

NPI: 1144478918
Provider Name (Legal Business Name): KELLY M CARPENTER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10740 MERIDIAN AVE N SUITE 110
SEATTLE WA
98133-9010
US

IV. Provider business mailing address

10740 MERIDIAN AVE N SUITE 110
SEATTLE WA
98133-9010
US

V. Phone/Fax

Practice location:
  • Phone: 206-696-2792
  • Fax:
Mailing address:
  • Phone: 206-696-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY00002546
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00002546
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPY00002546
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: