Provider Demographics
NPI:1346981511
Name:KELLY, ALICE (LMFT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12148 JOLLYVILLE RD APT 1301
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2240
Mailing Address - Country:US
Mailing Address - Phone:504-270-3834
Mailing Address - Fax:
Practice Address - Street 1:12148 JOLLYVILLE RD APT 1301
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2240
Practice Address - Country:US
Practice Address - Phone:504-270-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-04
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203732106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist