Provider Demographics
NPI:1275296311
Name:KELLY, SHANNON GENEEN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:GENEEN
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 1:17490 MEANDERING WAY APT 1207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-6150
Mailing Address - Country:US
Mailing Address - Phone:830-928-1088
Mailing Address - Fax:
Practice Address - Street 1:17490 MEANDERING WAY APT 1207
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-6150
Practice Address - Country:US
Practice Address - Phone:830-928-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011159321041C0700X
TX659611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical