Healthcare Provider Details

I. General information

NPI: 1427196658
Provider Name (Legal Business Name): KELLY SUZANNE HOUCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A FITZSIMMONS AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

PO BOX 33605
FORT LEWIS WA
98433-0605
US

V. Phone/Fax

Practice location:
  • Phone: 253-967-3096
  • Fax: 253-967-3096
Mailing address:
  • Phone: 423-676-8870
  • Fax: 423-467-3696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101236924
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD0101236924
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: