Healthcare Provider Details

I. General information

NPI: 1518919174
Provider Name (Legal Business Name): DENNIS ALLAN KELLY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSYCHOLOGY DEPT. MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-0001
US

IV. Provider business mailing address

2645 W LYNN ST
SEATTLE WA
98199-3522
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2784
  • Fax:
Mailing address:
  • Phone: 206-286-8338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY00001476
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: