Provider Demographics
NPI:1235721184
Name:FARRELL, KELLIE (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39625 N 1ST PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-7512
Mailing Address - Country:US
Mailing Address - Phone:520-465-2343
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE STE 410
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8732
Practice Address - Country:US
Practice Address - Phone:623-800-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-18218104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker