Provider Demographics
NPI:1861108417
Name:HENDERSON-WEAVER, KELSIE J
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:J
Last Name:HENDERSON-WEAVER
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 1:1025 S 3RD ST STE B
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2765
Mailing Address - Country:US
Mailing Address - Phone:206-624-6477
Mailing Address - Fax:
Practice Address - Street 1:1025 S 3RD ST STE B
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2765
Practice Address - Country:US
Practice Address - Phone:206-624-6477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health