Provider Demographics
NPI:1427563352
Name:WELCH, THEDORA
Entity Type:Individual
Prefix:
First Name:THEDORA
Middle Name:
Last Name:WELCH
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 1:307 DELORIS DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6277
Mailing Address - Country:US
Mailing Address - Phone:254-290-9786
Mailing Address - Fax:
Practice Address - Street 1:4008 E STAN SCHLUETER LOOP STE B
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-8548
Practice Address - Country:US
Practice Address - Phone:254-238-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-15-05643106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician