Provider Demographics
NPI:1669817573
Name:WINT BROWN, KELSEY (STUDENT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WINT BROWN
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:MISS
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:WINT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:230 N PARK BLVD
Mailing Address - Street 2:104
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6981
Mailing Address - Country:US
Mailing Address - Phone:817-421-0800
Mailing Address - Fax:
Practice Address - Street 1:230 N PARK BLVD
Practice Address - Street 2:104
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6981
Practice Address - Country:US
Practice Address - Phone:817-421-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12465OtherTEXAS BOARD OF CHIROPRACTIC EXAMINERS