Provider Demographics
NPI:1386190858
Name:GILLELAND, KELLY MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:GILLELAND
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WAIPAHOEHOE DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-2035
Mailing Address - Country:US
Mailing Address - Phone:512-718-1244
Mailing Address - Fax:
Practice Address - Street 1:148 WAIPAHOEHOE DR
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-2035
Practice Address - Country:US
Practice Address - Phone:512-718-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3607764-01Medicaid
TX3607764-02Medicaid