Provider Demographics
NPI:1104203660
Name:FOULKROD, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:FOULKROD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 BAY CITY BND
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78725-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4534 W GATE BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1485
Practice Address - Country:US
Practice Address - Phone:512-553-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34465101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor