Provider Demographics
NPI:1932889151
Name:HALL, KELLIE S (LMHCA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:S
Last Name:HALL
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CUSTER WAY SW STE B4
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3330
Mailing Address - Country:US
Mailing Address - Phone:360-467-6738
Mailing Address - Fax:
Practice Address - Street 1:204 CUSTER WAY SW SUITE B4
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-2916
Practice Address - Country:US
Practice Address - Phone:360-467-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61536196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health