1609183094 NPI number — DR. KELLY LYNN CHEATHAM PHD, LPC-S

Table of content: DR. KELLY LYNN CHEATHAM PHD, LPC-S (NPI 1609183094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609183094 NPI number — DR. KELLY LYNN CHEATHAM PHD, LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
KELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, LPC-S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609183094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2535 E SOUTHLAKE BLVD STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-228-1668
Provider Business Mailing Address Fax Number:
469-776-0669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2535 E SOUTHLAKE BLVD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-228-1668
Provider Business Practice Location Address Fax Number:
469-776-0669
Provider Enumeration Date:
09/07/2010

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:  65475 , 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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