Provider Demographics
NPI:1407280134
Name:BEACH, KEELY MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:MARIE
Last Name:BEACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1412
Mailing Address - Fax:360-729-3025
Practice Address - Street 1:1200 HILYARD ST STE 570
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8168
Practice Address - Country:US
Practice Address - Phone:458-205-7070
Practice Address - Fax:458-205-7089
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORL81911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor