Provider Demographics
NPI:1215369483
Name:KELLEY, CHRISTINA MARIE (DSW, LCSW, LISAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DSW, LCSW, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 N TATUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6039
Mailing Address - Country:US
Mailing Address - Phone:805-689-5542
Mailing Address - Fax:
Practice Address - Street 1:1111 E BROWN RD APT 117
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-4965
Practice Address - Country:US
Practice Address - Phone:805-689-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ217941041C0700X
CA1185261041C0700X
AZ15155101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1215369483Medicaid