Provider Demographics
NPI:1245616481
Name:MARTIN, KELLY A (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 EAGLE MOUNTAIN CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-9531
Mailing Address - Country:US
Mailing Address - Phone:817-733-2670
Mailing Address - Fax:
Practice Address - Street 1:8180 EAGLE MOUNTAIN CIR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-9531
Practice Address - Country:US
Practice Address - Phone:817-733-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional