Provider Demographics
NPI:1003406554
Name:KELLY, TRACI (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:ANN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:9636 LEA SHORE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3225
Mailing Address - Country:US
Mailing Address - Phone:817-682-0163
Mailing Address - Fax:
Practice Address - Street 1:9636 LEA SHORE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3225
Practice Address - Country:US
Practice Address - Phone:817-682-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-47100103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst