Provider Demographics
NPI:1598394546
Name:KETZ, KELLI (LICSW)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KETZ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2420
Mailing Address - Country:US
Mailing Address - Phone:304-575-1765
Mailing Address - Fax:
Practice Address - Street 1:101 S EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4929
Practice Address - Country:US
Practice Address - Phone:304-256-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009451041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDP00945104OtherSOCIAL WORK LICENSE