Provider Demographics
NPI:1174117923
Name:BRIELOFF KELLY, DIANE (RCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BRIELOFF KELLY
Suffix:
Gender:F
Credentials:RCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ADAM RD W
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-8003
Mailing Address - Country:US
Mailing Address - Phone:516-972-0031
Mailing Address - Fax:
Practice Address - Street 1:27 ADAM RD W
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-8003
Practice Address - Country:US
Practice Address - Phone:516-972-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043361-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical