Provider Demographics
NPI:1679247712
Name:MCKELLAR, LAURA (CBT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MCKELLAR
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 PINEHURST DR SW APT 202
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5282
Mailing Address - Country:US
Mailing Address - Phone:208-965-9993
Mailing Address - Fax:
Practice Address - Street 1:3443 LILLY RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-3091
Practice Address - Country:US
Practice Address - Phone:360-456-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61173725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician