Provider Demographics
NPI:1093281040
Name:FROSCH, KELLY A (BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:FROSCH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12105 LA SALLE BR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4222
Mailing Address - Country:US
Mailing Address - Phone:936-537-3918
Mailing Address - Fax:
Practice Address - Street 1:233 SGT ED HOLCOMB BLVD S
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-1990
Practice Address - Country:US
Practice Address - Phone:936-521-6291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2279103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst