Provider Demographics
NPI:1134372006
Name:ESTLE, KELLY DIANTHA (LCSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DIANTHA
Last Name:ESTLE
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:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:AL
Mailing Address - Zip Code:36572-1002
Mailing Address - Country:US
Mailing Address - Phone:251-709-6964
Mailing Address - Fax:
Practice Address - Street 1:1504 SPRINGHILL AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-709-6964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2034C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical