Healthcare Provider Details

I. General information

NPI: 1043584758
Provider Name (Legal Business Name): ELLY J BEACH LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 COMMERCE AVE STE 315A
LONGVIEW WA
98632-3729
US

IV. Provider business mailing address

1222 10TH AVE
LONGVIEW WA
98632-3108
US

V. Phone/Fax

Practice location:
  • Phone: 360-425-1826
  • Fax:
Mailing address:
  • Phone: 360-846-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60266172
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: