Provider Demographics
NPI:1457450520
Name:KELLY, DIANNE FLINT (MS)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:FLINT
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 COLLINS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1794
Mailing Address - Country:US
Mailing Address - Phone:404-822-8867
Mailing Address - Fax:
Practice Address - Street 1:2759 DELK RD SE
Practice Address - Street 2:SUITE 2300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8847
Practice Address - Country:US
Practice Address - Phone:404-822-8867
Practice Address - Fax:770-484-2749
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6825101YM0800X
GA003356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health