Provider Demographics
NPI:1891209599
Name:HEWSON, KAELYN MARIE (SUDP)
Entity type:Individual
Prefix:
First Name:KAELYN
Middle Name:MARIE
Last Name:HEWSON
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:KAELYN
Other - Middle Name:MARIE
Other - Last Name:RIBARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDPT, AA
Mailing Address - Street 1:11401 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5500
Mailing Address - Country:US
Mailing Address - Phone:425-218-8172
Mailing Address - Fax:
Practice Address - Street 1:9930 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3883
Practice Address - Country:US
Practice Address - Phone:425-347-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60336491101YA0400X
WACP60878508101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)