Provider Demographics
NPI:1659844769
Name:KELLY, ANEISHA LICHELLE
Entity Type:Individual
Prefix:MS
First Name:ANEISHA
Middle Name:LICHELLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 FONDREN RD APT 1326
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-2341
Mailing Address - Country:US
Mailing Address - Phone:803-414-4264
Mailing Address - Fax:
Practice Address - Street 1:6701 PINEMONT DR STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-3131
Practice Address - Country:US
Practice Address - Phone:832-209-7830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty