Healthcare Provider Details

I. General information

NPI: 1659820991
Provider Name (Legal Business Name): KELSEY WALLACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2719 E MADISON ST STE 300
SEATTLE WA
98112-4752
US

IV. Provider business mailing address

2719 E MADISON ST STE 300
SEATTLE WA
98112-4752
US

V. Phone/Fax

Practice location:
  • Phone: 206-669-4336
  • Fax: 206-302-2210
Mailing address:
  • Phone: 206-669-4336
  • Fax: 206-302-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number60781378
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: