Healthcare Provider Details

I. General information

NPI: 1386145274
Provider Name (Legal Business Name): KELLY S ANDERSON MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 NE 41ST ST STE 200
VANCOUVER WA
98662-6772
US

IV. Provider business mailing address

100 N HOWARD ST STE W
SPOKANE WA
99201-0508
US

V. Phone/Fax

Practice location:
  • Phone: 564-208-0023
  • Fax:
Mailing address:
  • Phone: 564-208-0023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMC61499734
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: