Healthcare Provider Details

I. General information

NPI: 1134894371
Provider Name (Legal Business Name): KELLY TABET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

2700 N CENTRAL AVE STE 1050
PHOENIX AZ
85004-1217
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0398
  • Fax: 602-933-5525
Mailing address:
  • Phone: 602-266-8402
  • Fax: 602-264-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-19479
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: