Provider Demographics
NPI:1821753591
Name:KELLEY, MARY LEE (LCDC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6619 WHITNEYGLEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-3785
Mailing Address - Country:US
Mailing Address - Phone:214-414-6797
Mailing Address - Fax:
Practice Address - Street 1:4645 SAMUELL BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6826
Practice Address - Country:US
Practice Address - Phone:214-743-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15183101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)