MEDICARE: DR. KELLY HUGHES BERARDI PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY21984	CA
2	103TC0700X	Clinical Psychologist	PY60272993	WA

General Provider Information

NPI Number	:	1720248560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY HUGHES BERARDI PHD

Provider Business Mailing Address
First Line	:	320 NE 97TH ST
Second Line	:	SUITE A
City	:	SEATTLE
State	:	WA
Zip	:	98115-2042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 NE 97TH ST
Second Line	:	SUITE A
City	:	SEATTLE
State	:	WA
Zip	:	98115-2042
Country	:	US
Telephone Number	:	206-453-5707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	12/20/2016

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