Provider Demographics
NPI:1790019826
Name:PILGRIM, MISTY SMITH (MED, MA, LICSW)
Entity type:Individual
Prefix:MS
First Name:MISTY
Middle Name:SMITH
Last Name:PILGRIM
Suffix:
Gender:F
Credentials:MED, MA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 VILLAGE WAY # 107
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-5102
Mailing Address - Country:US
Mailing Address - Phone:505-501-8293
Mailing Address - Fax:505-521-5149
Practice Address - Street 1:46 VILLAGE WAY # 107
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-5102
Practice Address - Country:US
Practice Address - Phone:505-501-8293
Practice Address - Fax:505-521-5149
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2022-01891041C0700X
WALW615578251041C0700X
HILCSW-50661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical