Provider Demographics
NPI:1063614162
Name:GATHERCOAL, BECKY JANELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:JANELLE
Last Name:GATHERCOAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:BECKY
Other - Middle Name:JANELLE
Other - Last Name:GATHERCOAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1512 NORDIC CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5299
Mailing Address - Country:US
Mailing Address - Phone:541-840-7775
Mailing Address - Fax:541-500-1818
Practice Address - Street 1:3550 NATIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7309
Practice Address - Country:US
Practice Address - Phone:541-772-8680
Practice Address - Fax:541-500-1818
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR119339Medicare ID - Type Unspecified