Provider Demographics
NPI:1538806237
Name:CULLEN, KELLIE LEE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LEE
Last Name:CULLEN
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 1:5609 AINSDALE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-1446
Mailing Address - Country:US
Mailing Address - Phone:817-237-7911
Mailing Address - Fax:
Practice Address - Street 1:5100 EL CAMPO AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4864
Practice Address - Country:US
Practice Address - Phone:817-814-6400
Practice Address - Fax:817-814-6450
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist