Provider Demographics
NPI:1508216631
Name:AUSTIN, KELLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7118 KNOTTY OAK LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-3235
Mailing Address - Country:US
Mailing Address - Phone:571-445-0265
Mailing Address - Fax:
Practice Address - Street 1:7118 KNOTTY OAK LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3235
Practice Address - Country:US
Practice Address - Phone:571-445-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001391106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0717001391OtherSTATE LICENSE