Provider Demographics
NPI:1174213250
Name:DIAZ-HYDE, KELLY ANN (MSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:DIAZ-HYDE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 YOHO CIR
Mailing Address - Street 2:
Mailing Address - City:LIMERICK
Mailing Address - State:ME
Mailing Address - Zip Code:04048-3491
Mailing Address - Country:US
Mailing Address - Phone:954-415-5910
Mailing Address - Fax:
Practice Address - Street 1:55 FODEN RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1717
Practice Address - Country:US
Practice Address - Phone:207-854-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX20864104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker