Provider Demographics
NPI:1497872493
Name:PEDERSEN, KELLY LEIGH (LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LEIGH
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 COPPERLEAF RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4246
Mailing Address - Country:US
Mailing Address - Phone:512-963-3660
Mailing Address - Fax:
Practice Address - Street 1:317 COPPERLEAF RD
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4246
Practice Address - Country:US
Practice Address - Phone:512-963-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20301101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1814584-01Medicaid