Provider Demographics
NPI:1588226609
Name:VASCONEZ, KECIA MARIETTE (LCDC, MS MFT/C)
Entity Type:Individual
Prefix:
First Name:KECIA
Middle Name:MARIETTE
Last Name:VASCONEZ
Suffix:
Gender:F
Credentials:LCDC, MS MFT/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 W AIRPORT FWY STE 430
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-5984
Mailing Address - Country:US
Mailing Address - Phone:972-607-0088
Mailing Address - Fax:
Practice Address - Street 1:4425 W AIRPORT FWY STE 430
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5984
Practice Address - Country:US
Practice Address - Phone:972-607-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
TX16869101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty