Provider Demographics
NPI:1922022243
Name:KELLEY, VIRGINIA (LCSW)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:KELLEY
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 1:4300 N MILLER RD
Mailing Address - Street 2:STE. 218
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3619
Mailing Address - Country:US
Mailing Address - Phone:480-429-6390
Mailing Address - Fax:480-836-4527
Practice Address - Street 1:4300 N MILLER RD
Practice Address - Street 2:STE. 218
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3619
Practice Address - Country:US
Practice Address - Phone:480-429-6390
Practice Address - Fax:480-836-4527
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-35941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85140Medicare ID - Type UnspecifiedLOCAL NUMBER