Provider Demographics
NPI:1023199973
Name:BAUER, KELLY (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2099 N COLLINS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2698
Mailing Address - Country:US
Mailing Address - Phone:972-437-4698
Mailing Address - Fax:972-671-2087
Practice Address - Street 1:11200 WAPLES MILL RD
Practice Address - Street 2:SUITE 180
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7407
Practice Address - Country:US
Practice Address - Phone:703-383-8333
Practice Address - Fax:703-383-3183
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional