Provider Demographics
NPI:1417931924
Name:KELLY EVANS JOSLIN
Entity Type:Organization
Organization Name:KELLY EVANS JOSLIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:JOSLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:903-796-0776
Mailing Address - Street 1:PO BOX 943
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-0943
Mailing Address - Country:US
Mailing Address - Phone:903-796-0776
Mailing Address - Fax:903-799-9776
Practice Address - Street 1:604 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-2529
Practice Address - Country:US
Practice Address - Phone:903-796-0776
Practice Address - Fax:903-799-9776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10888101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125519-0002OtherCHIPS PROV.#
TX2163LCOtherBLUECROSS/BLUE SHIELD