Provider Demographics
NPI:1639040967
Name:PHAM, KELLY BAO-UYEN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BAO-UYEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 SLADE WAY
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2766
Mailing Address - Country:US
Mailing Address - Phone:206-769-8710
Mailing Address - Fax:
Practice Address - Street 1:221 WELLS AVE S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2161
Practice Address - Country:US
Practice Address - Phone:253-833-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health