Provider Demographics
NPI:1144691056
Name:KELLY, KATRINA ALMA (LMSW)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ALMA
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HERITAGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:78612-3346
Mailing Address - Country:US
Mailing Address - Phone:361-960-9034
Mailing Address - Fax:
Practice Address - Street 1:125 HERITAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:CEDAR CREEK
Practice Address - State:TX
Practice Address - Zip Code:78612-3346
Practice Address - Country:US
Practice Address - Phone:361-960-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11398101YA0400X
TX61384104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)