Provider Demographics
NPI:1811724578
Name:MASTERS, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MASTERS
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 1:1635 LAKESIDE DR W
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-5820
Mailing Address - Country:US
Mailing Address - Phone:210-789-5402
Mailing Address - Fax:
Practice Address - Street 1:122 W LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-4322
Practice Address - Country:US
Practice Address - Phone:210-789-5402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician