Provider Demographics
NPI:1790922235
Name:GILMORE, KELLY LYNN (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:GILMORE
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 1:8285 SW NIMBUS AVE STE 148
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6465
Mailing Address - Country:US
Mailing Address - Phone:503-941-8877
Mailing Address - Fax:
Practice Address - Street 1:8285 SW NIMBUS AVE STE 148
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6465
Practice Address - Country:US
Practice Address - Phone:503-941-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR75721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical