Provider Demographics
NPI:1306320494
Name:TONGG, KELLY (LSWAIC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TONGG
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TERAKAWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:515 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2304
Mailing Address - Country:US
Mailing Address - Phone:206-464-1570
Mailing Address - Fax:
Practice Address - Street 1:515 3RD AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2304
Practice Address - Country:US
Practice Address - Phone:206-464-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60778321104100000X
WALW610062721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker