Healthcare Provider Details

I. General information

NPI: 1619569605
Provider Name (Legal Business Name): KELLY GRIFFIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S SPRING ST
SPRINGFIELD IL
62704-2725
US

IV. Provider business mailing address

920 S SPRING ST
SPRINGFIELD IL
62704-2725
US

V. Phone/Fax

Practice location:
  • Phone: 919-275-2835
  • Fax:
Mailing address:
  • Phone: 919-275-2835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.022965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: