Provider Demographics
NPI:1942417035
Name:KELLY, DIANE G (LCSW MSW)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:G
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW MSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:G
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW MSW
Mailing Address - Street 1:4165 WARNER AVE
Mailing Address - Street 2:UNIT 302
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4255
Mailing Address - Country:US
Mailing Address - Phone:949-244-6140
Mailing Address - Fax:
Practice Address - Street 1:260 NEWPORT CENTER DR
Practice Address - Street 2:STE 203
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7520
Practice Address - Country:US
Practice Address - Phone:949-244-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS110051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS11005OtherLCSW