Provider Demographics
NPI:1164207726
Name:KELLEY, KAYLEE CASSANDRA
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:CASSANDRA
Last Name:KELLEY
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 1:1803 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6404
Mailing Address - Country:US
Mailing Address - Phone:830-480-4766
Mailing Address - Fax:
Practice Address - Street 1:1803 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6404
Practice Address - Country:US
Practice Address - Phone:830-480-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician