Provider Demographics
NPI:1790397834
Name:KELLY, GLORIA (MA)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:13818 DENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-2665
Mailing Address - Country:US
Mailing Address - Phone:832-716-4441
Mailing Address - Fax:
Practice Address - Street 1:13818 DENTWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-2665
Practice Address - Country:US
Practice Address - Phone:832-716-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174200000XOther Service ProvidersMeals
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No305S00000XManaged Care OrganizationsPoint of Service