Provider Demographics
NPI:1710346622
Name:DUKE, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DUKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150425
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78715-0425
Mailing Address - Country:US
Mailing Address - Phone:512-787-6979
Mailing Address - Fax:
Practice Address - Street 1:8700 MANCHACA RD
Practice Address - Street 2:SUITE 605
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5371
Practice Address - Country:US
Practice Address - Phone:512-787-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX521041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3579591-01Medicaid