Provider Demographics
NPI:1750034047
Name:KELLY, SAUDIA DARICE
Entity Type:Individual
Prefix:
First Name:SAUDIA
Middle Name:DARICE
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 1:4815 EMBERS DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4579
Mailing Address - Country:US
Mailing Address - Phone:210-391-4437
Mailing Address - Fax:
Practice Address - Street 1:4815 EMBERS DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4579
Practice Address - Country:US
Practice Address - Phone:210-391-4437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty