Provider Demographics
NPI:1275015323
Name:KELLY, ASHLEY MECHELLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MECHELLE
Last Name:KELLY
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 1:2320 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-1276
Mailing Address - Country:US
Mailing Address - Phone:254-752-1075
Mailing Address - Fax:254-754-0504
Practice Address - Street 1:2320 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-1276
Practice Address - Country:US
Practice Address - Phone:254-752-1075
Practice Address - Fax:254-754-0504
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214194225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist