Provider Demographics
NPI:1861604571
Name:GUTHRIE, KELLY DIONE (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DIONE
Last Name:GUTHRIE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 TAFT BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-1243
Mailing Address - Country:US
Mailing Address - Phone:940-631-6620
Mailing Address - Fax:940-766-6662
Practice Address - Street 1:2707 TAFT BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-1243
Practice Address - Country:US
Practice Address - Phone:940-631-6620
Practice Address - Fax:940-766-6662
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31588103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00639HMedicaid
TX00639HMedicare ID - Type Unspecified