Provider Demographics
NPI:1689732786
Name:KELLY, GWYNETTH E (DBH)
Entity Type:Individual
Prefix:DR
First Name:GWYNETTH
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:DBH
Other - Prefix:MS
Other - First Name:GWYNETTH
Other - Middle Name:E
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 86881
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-6881
Mailing Address - Country:US
Mailing Address - Phone:602-320-7925
Mailing Address - Fax:
Practice Address - Street 1:15600 N BLACK CANYON HWY # C103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4055
Practice Address - Country:US
Practice Address - Phone:602-320-7925
Practice Address - Fax:877-958-9033
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-154921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical