Healthcare Provider Details

I. General information

NPI: 1467199729
Provider Name (Legal Business Name): KELLI DIANE ZURLIENE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W 1ST ST
AVISTON IL
62216-3440
US

IV. Provider business mailing address

13030 BUCKEYE RD
HIGHLAND IL
62249-4400
US

V. Phone/Fax

Practice location:
  • Phone: 618-228-7615
  • Fax:
Mailing address:
  • Phone: 618-830-9319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.020843
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: