Provider Demographics
NPI:1477335503
Name:MADENWALD, KELSEY ALYSSA
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:ALYSSA
Last Name:MADENWALD
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 1:5304 PRINCE LN
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-8103
Mailing Address - Country:US
Mailing Address - Phone:214-755-6112
Mailing Address - Fax:
Practice Address - Street 1:3740 N JOSEY LN STE 145
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-2471
Practice Address - Country:US
Practice Address - Phone:469-701-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health