Provider Demographics
NPI:1003209024
Name:HOUSTON, KELLY (RDN, LD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 VADALABENE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5636
Mailing Address - Country:US
Mailing Address - Phone:618-288-7408
Mailing Address - Fax:618-288-7418
Practice Address - Street 1:2023 VADALABENE DR STE 200
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5636
Practice Address - Country:US
Practice Address - Phone:618-288-7408
Practice Address - Fax:618-288-7418
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013038254133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered