Provider Demographics
NPI:1770937583
Name:GIN, KELLY (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:GIN
Suffix:
Gender:F
Credentials:PHD, LP
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 1911
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78630-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13276 RESEARCH BLVD
Practice Address - Street 2:203
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-3236
Practice Address - Country:US
Practice Address - Phone:512-966-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36703103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist