Provider Demographics
NPI:1972983856
Name:KELLY, DEQUITA
Entity Type:Individual
Prefix:
First Name:DEQUITA
Middle Name:
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 1:2108 RODNEY LN
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-1369
Mailing Address - Country:US
Mailing Address - Phone:214-290-4650
Mailing Address - Fax:
Practice Address - Street 1:2108 RODNEY LN
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75180-1369
Practice Address - Country:US
Practice Address - Phone:214-290-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities