Provider Demographics
NPI:1083147243
Name:KELLEY, AGNES (LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:AGNES
Other - Middle Name:
Other - Last Name:VAN BRUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3003 S LOOP W STE 320
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-1373
Mailing Address - Country:US
Mailing Address - Phone:713-910-0296
Mailing Address - Fax:
Practice Address - Street 1:3003 S LOOP W STE 320
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-1373
Practice Address - Country:US
Practice Address - Phone:713-910-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional