Provider Demographics
NPI:1285072157
Name:KAUTZMAN, KELLEY L
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:L
Last Name:KAUTZMAN
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:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98595-0136
Mailing Address - Country:US
Mailing Address - Phone:360-589-0675
Mailing Address - Fax:
Practice Address - Street 1:106 F STREET
Practice Address - Street 2:
Practice Address - City:COSMOPOLIS
Practice Address - State:WA
Practice Address - Zip Code:98537
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant