Provider Demographics
NPI:1952468829
Name:BETH, KELLY GILL (LCSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:GILL
Last Name:BETH
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:GILL
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3516 RUST ST
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-2178
Mailing Address - Country:US
Mailing Address - Phone:253-583-2727
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:A-116-MHC
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-0003
Practice Address - Country:US
Practice Address - Phone:253-583-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1880C101Y00000X
WALW604457281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL273814OtherCOMPSYCH
AL273814OtherCOMPSYCH