Provider Demographics
NPI:1720288806
Name:KELLY DILWORTH, CAROL ANN (LBSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:KELLY DILWORTH
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7555 FOSS MDWS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78244-2250
Mailing Address - Country:US
Mailing Address - Phone:210-875-4663
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:7555 FOSS MDWS
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-2250
Practice Address - Country:US
Practice Address - Phone:210-875-4663
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25770104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25770OtherTEXAS STATE BOARD OF SOCI