Provider Demographics
NPI:1629420047
Name:TAYLOR-VERVALIN, KELLY (LCDC-I)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TAYLOR-VERVALIN
Suffix:
Gender:F
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14002 TOWNE WAY DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-1570
Mailing Address - Country:US
Mailing Address - Phone:832-877-2121
Mailing Address - Fax:
Practice Address - Street 1:1820 COUNTY ROAD 36
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-8727
Practice Address - Country:US
Practice Address - Phone:832-877-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17430324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility