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General NPI Number Information
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NPI Number | 1942417035
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Entity Type | Individual
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Provider Name | DIANE G KELLY LCSW MSW
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Gender | Female
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 08/06/2012
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Provider Practice Location Address
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Address Line | 260 NEWPORT CENTER DR STE 203
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-7520
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Country | US
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Telephone | 949-244-6140
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Fax |
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Provider Business Mailing Address
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Address Line | 4165 WARNER AVE UNIT 302
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92649-4255
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Country | US
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Telephone | 949-244-6140
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS11005
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License Number State | CA
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