Provider Demographics
NPI:1689665788
Name:CZEISZPERGER, KELLY LYNN (CSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:CZEISZPERGER
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554
Mailing Address - Street 2:ATTN: 59 MDW/SGHC
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-6225
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554
Practice Address - Street 2:ATTN: 59 MDW/SGHC
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical