Provider Demographics
NPI:1396401212
Name:MANUEL, KELLY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:MANUEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:MANUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:157 LISA LN UNIT B
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-5782
Mailing Address - Country:US
Mailing Address - Phone:512-743-9583
Mailing Address - Fax:
Practice Address - Street 1:111 N HASLER BLVD STE 219
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3984
Practice Address - Country:US
Practice Address - Phone:512-743-9573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical