Provider Demographics
NPI:1609183094
Name:CHEATHAM, KELLY LYNN (PHD, LPC-S)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LYNN
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:PHD, LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 HIDDEN MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-8426
Mailing Address - Country:US
Mailing Address - Phone:817-228-1668
Mailing Address - Fax:
Practice Address - Street 1:4300 MACARTHUR AVE STE 215
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-6524
Practice Address - Country:US
Practice Address - Phone:817-228-1668
Practice Address - Fax:817-416-4644
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65475101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional