Provider Demographics
NPI:1891233789
Name:KINCHELOE, VANESSA (PHD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:KINCHELOE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 TAFT BLVD
Mailing Address - Street 2:2
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-4872
Mailing Address - Country:US
Mailing Address - Phone:940-691-1899
Mailing Address - Fax:940-691-3423
Practice Address - Street 1:4722 TAFT BLVD
Practice Address - Street 2:2
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4872
Practice Address - Country:US
Practice Address - Phone:940-691-1899
Practice Address - Fax:940-691-3423
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical