Provider Demographics
NPI:1538478482
Name:GONZALEZ-MIRANDA, KELLY MARCELLE (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARCELLE
Last Name:GONZALEZ-MIRANDA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ARNET
Other - Last Name:MARCELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 3067
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77305-3067
Mailing Address - Country:US
Mailing Address - Phone:936-521-6338
Mailing Address - Fax:
Practice Address - Street 1:1020 RIVERWOOD COURT BLDG 1
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2206
Practice Address - Country:US
Practice Address - Phone:936-521-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2016-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65259101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional