Provider Demographics
NPI:1164043741
Name:HERGERT, KELSEY JO (LCSW, LICSW)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:HERGERT
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:JO
Other - Last Name:ZETTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LICSW
Mailing Address - Street 1:15037 TAHOMA BLVD SE APT C108
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-7770
Mailing Address - Country:US
Mailing Address - Phone:815-291-3542
Mailing Address - Fax:
Practice Address - Street 1:15037 TAHOMA BLVD SE APT C108
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7770
Practice Address - Country:US
Practice Address - Phone:815-291-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL141421041C0700X
WALW614483261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical