Provider Demographics
NPI:1437794856
Name:DUKE, KELSY RAE
Entity Type:Individual
Prefix:
First Name:KELSY
Middle Name:RAE
Last Name:DUKE
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 1:15200 PARK ROW APT 1022
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-5174
Mailing Address - Country:US
Mailing Address - Phone:979-571-4018
Mailing Address - Fax:
Practice Address - Street 1:15200 PARK ROW APT 1022
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5174
Practice Address - Country:US
Practice Address - Phone:979-571-4018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-16-27648106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-16-27648Medicaid