Provider Demographics
NPI:1891189429
Name:DIGUILIO, KELLY C (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:DIGUILIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:DIGUILIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5500 WHITE SWALLOW WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2330
Mailing Address - Country:US
Mailing Address - Phone:707-490-9764
Mailing Address - Fax:
Practice Address - Street 1:5500 WHITE SWALLOW WAY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2330
Practice Address - Country:US
Practice Address - Phone:707-490-9764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK467104100000X
FLSW195151041C0700X
NCC0130891041C0700X
VA09040098981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891189429Medicaid
NCC013089OtherLCSW
VA0904009898OtherLCSW
AK508559OtherMASTER IN ADDICTION CERTIFICATION
FLSW19515OtherLCSW
VA1891189429Medicaid