Provider Demographics
NPI:1740420298
Name:NOWOTNY, KELLY ERIN (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ERIN
Last Name:NOWOTNY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8613 ROCK PIGEON DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-8086
Mailing Address - Country:US
Mailing Address - Phone:512-470-3539
Mailing Address - Fax:
Practice Address - Street 1:12319 WILLOW WILD DR STE B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2725
Practice Address - Country:US
Practice Address - Phone:512-470-3539
Practice Address - Fax:512-837-3131
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208050902Medicaid