=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558860049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY KUSTOK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 914 140TH AVE NE STE 201
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98005-3482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33568
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92163-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax | 619-374-7134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-23-67055
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BA61474114
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-23-67055
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 3657
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------