Provider Demographics
NPI:1053622829
Name:DICENSO, KELLY G (LSCW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:DICENSO
Suffix:
Gender:F
Credentials:LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 OHIO BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2239
Mailing Address - Country:US
Mailing Address - Phone:812-232-2144
Mailing Address - Fax:812-234-4598
Practice Address - Street 1:2901 OHIO BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-2239
Practice Address - Country:US
Practice Address - Phone:812-232-2144
Practice Address - Fax:812-234-4598
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN34005990A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical