Provider Demographics
NPI:1881025302
Name:KELLY, WILLIAM NATHANIEL III (LCSW)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:NATHANIEL
Last Name:KELLY
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1326
Mailing Address - Country:US
Mailing Address - Phone:803-467-7385
Mailing Address - Fax:
Practice Address - Street 1:10509 SAN DIEGO MISSION RD STE P
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2202
Practice Address - Country:US
Practice Address - Phone:619-500-7088
Practice Address - Fax:619-314-4252
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA864261041C0700X
NCC0118801041C0700X
MD156811041C0700X
SC128661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical