Healthcare Provider Details

I. General information

NPI: 1073626453
Provider Name (Legal Business Name): WILLIAM SAMUEL KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 VETERANS DR SW
TACOMA WA
98493-0003
US

IV. Provider business mailing address

9600 VETERANS DR SW
TACOMA WA
98493-0003
US

V. Phone/Fax

Practice location:
  • Phone: 253-583-1698
  • Fax: 253-589-4167
Mailing address:
  • Phone: 253-583-1698
  • Fax: 253-589-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33548
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: