Provider Demographics
NPI:1134249873
Name:KELLY, JOSEPHINE SALLY (MAMFC MA OF MARRIAGE)
Entity type:Individual
Prefix:MRS
First Name:JOSEPHINE
Middle Name:SALLY
Last Name:KELLY
Suffix:
Gender:F
Credentials:MAMFC MA OF MARRIAGE
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JOSEPHINE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC MAMFC
Mailing Address - Street 1:101 E WALKER ST
Mailing Address - Street 2:SUITE 512 & 513
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424
Mailing Address - Country:US
Mailing Address - Phone:254-559-8508
Mailing Address - Fax:254-559-8508
Practice Address - Street 1:101 E WALKER ST
Practice Address - Street 2:SUITE 512 & 513
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424
Practice Address - Country:US
Practice Address - Phone:254-559-8508
Practice Address - Fax:254-559-8508
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12570101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional