Provider Demographics
NPI:1225120819
Name:DIAL, KELLY J (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:DIAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3838
Mailing Address - Country:US
Mailing Address - Phone:217-744-3525
Mailing Address - Fax:217-744-3535
Practice Address - Street 1:215 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3838
Practice Address - Country:US
Practice Address - Phone:217-744-3525
Practice Address - Fax:217-744-3535
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490077841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08425920OtherBCBS
IL249424000OtherMAGELLAN