Provider Demographics
NPI:1073347704
Name:SMITH, KELSEY MARIE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:SMITH
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 1:6008 MAPLE AVE APT 156
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-6565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3101 STONEFIELD
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-6568
Practice Address - Country:US
Practice Address - Phone:972-947-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121101235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist