Provider Demographics
NPI:1407359920
Name:KELLY, CHRISTY ANN
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:ANN
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 1:197 VALERO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6869
Mailing Address - Country:US
Mailing Address - Phone:512-216-5426
Mailing Address - Fax:
Practice Address - Street 1:400 E ROYAL LN BLDG 3
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3540
Practice Address - Country:US
Practice Address - Phone:512-216-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-35733106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician