Provider Demographics
NPI:1053902320
Name:PRICE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 S 74TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-1005
Mailing Address - Country:US
Mailing Address - Phone:360-207-3439
Mailing Address - Fax:
Practice Address - Street 1:3906 S 74TH ST STE 201
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-1005
Practice Address - Country:US
Practice Address - Phone:360-207-3439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60908776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical