Provider Demographics
NPI:1033102603
Name:JOSLIN, KELLY EVANS (MED, LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EVANS
Last Name:JOSLIN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 943
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-0943
Mailing Address - Country:US
Mailing Address - Phone:903-796-0776
Mailing Address - Fax:903-799-9776
Practice Address - Street 1:604 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-2529
Practice Address - Country:US
Practice Address - Phone:903-796-0776
Practice Address - Fax:903-799-9776
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10888101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2163LCOtherBC/BS PROVIDER NUMBER