Provider Demographics
NPI:1265693030
Name:STALLINGS, KELLIE R
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:R
Last Name:STALLINGS
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:PO BOX 311268
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78131-1268
Mailing Address - Country:US
Mailing Address - Phone:830-629-6571
Mailing Address - Fax:830-608-1262
Practice Address - Street 1:1414 W SAN ANTONIO
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6202
Practice Address - Country:US
Practice Address - Phone:830-629-6571
Practice Address - Fax:830-608-1262
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0406027-01Medicaid