Provider Demographics
NPI:1952840944
Name:GRAVELLE, KELSEY RAE (SUDP LICSW)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:RAE
Last Name:GRAVELLE
Suffix:
Gender:
Credentials:SUDP LICSW
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:RAE
Other - Last Name:DELAGRANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSWA SUDP
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-353-9422
Mailing Address - Fax:360-423-7813
Practice Address - Street 1:900 FIR ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2544
Practice Address - Country:US
Practice Address - Phone:360-575-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60714593101YA0400X
WALW616777311041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor