1134249873 NPI number — MRS. JOSEPHINE SALLY KELLY MAMFC MA OF MARRIAGE

Table of content: MRS. JOSEPHINE SALLY KELLY MAMFC MA OF MARRIAGE (NPI 1134249873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134249873 NPI number — MRS. JOSEPHINE SALLY KELLY MAMFC MA OF MARRIAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
JOSEPHINE
Provider Middle Name:
SALLY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MAMFC MA OF MARRIAGE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY
Provider Other First Name:
SALLY
Provider Other Middle Name:
JOSEPHINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC MAMFC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1134249873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E WALKER ST
Provider Second Line Business Mailing Address:
SUITE 512 & 513
Provider Business Mailing Address City Name:
BRECKENRIDGE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-559-8508
Provider Business Mailing Address Fax Number:
254-559-8508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E WALKER ST
Provider Second Line Business Practice Location Address:
SUITE 512 & 513
Provider Business Practice Location Address City Name:
BRECKENRIDGE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-559-8508
Provider Business Practice Location Address Fax Number:
254-559-8508
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  12570 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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