Healthcare Provider Details

I. General information

NPI: 1225120819
Provider Name (Legal Business Name): KELLY J DIAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S GRAND AVE W
SPRINGFIELD IL
62704-3838
US

IV. Provider business mailing address

215 S GRAND AVE W
SPRINGFIELD IL
62704-3838
US

V. Phone/Fax

Practice location:
  • Phone: 217-744-3525
  • Fax: 217-744-3535
Mailing address:
  • Phone: 217-744-3525
  • Fax: 217-744-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149007784
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: