=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285863399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY DIANE KRISSEL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2009
-----------------------------------------------------
Last Update Date | 12/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3033 WILSON BLVD STE 700
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22201-3868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-324-9869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2610 MARCEY RD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22207-5232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-324-9869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW 8985
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------