Provider Demographics
NPI:1306167879
Name:RICHARDSON, KELLY GOLLIHER (DNP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:GOLLIHER
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 COPPER CRK
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-3921
Mailing Address - Country:US
Mailing Address - Phone:210-386-8940
Mailing Address - Fax:
Practice Address - Street 1:5616 COPPER CRK
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-3921
Practice Address - Country:US
Practice Address - Phone:210-386-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2021032810364SP0813X
TX2010007126207QG0300X
TX636991363L00000X
TX2013010497207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Geropsychiatric
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306167879Medicaid