MEDICARE: DR. KATHERINE JANE KELLY PH.D.

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	103TC1900X	Counseling Psychologist	PY60563485	WA
2	103TC1900X	Counseling Psychologist	102699	NC
3	103TH0100X	Health Service Psychologist	1070	SC
4	103T00000X	Psychologist	PY60563485	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841483286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE JANE KELLY PH.D.

Provider Business Mailing Address
First Line	:	14900 INTERURBAN AVE S STE 271
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98168-4654
Country	:	US
Telephone Number	:	425-757-2920
Fax Number	:

Provider Business Practice Location Address
First Line	:	9040 JACKSON AVENUE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98531
Country	:	US
Telephone Number	:	425-757-2920
Fax Number	:

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

Provider Enumeration Date	:	08/20/2007
Last Update Date	:	03/13/2019

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