Provider Demographics
NPI:1699269837
Name:MCKEON, KELLY (LMT)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MCKEON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 COOPER POINT RD SW #27 #12228
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-951-4504
Mailing Address - Fax:877-848-7757
Practice Address - Street 1:8650 MARTIN WAY E STE 207
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6610
Practice Address - Country:US
Practice Address - Phone:360-951-4504
Practice Address - Fax:877-848-7757
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60855605225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist