Healthcare Provider Details

I. General information

NPI: 1649731217
Provider Name (Legal Business Name): LAUREL LEA KELLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE STE 100L-1
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-7283
  • Fax: 509-277-7070
Mailing address:
  • Phone: 509-474-6661
  • Fax: 509-277-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60886231
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW60886231
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: