Basic Information
| Provider Information | |||||||||
| NPI: | 1407189756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D., ABPP, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152090 | ||||||||
| FaxNumber: | 2062153099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 07/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 60056916 | WA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 103TC0700X | PSY-1225 | HI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PY 60130390 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | H00433047 | 01 | HI | DRIVERS LICENSE | OTHER |