Provider Demographics
NPI:1982163788
Name:STINSON, KELLESHA K (LCDC)
Entity type:Individual
Prefix:
First Name:KELLESHA
Middle Name:K
Last Name:STINSON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:K
Other - Last Name:STINSON-BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:6306 WINDCREST DR APT 1733
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3028
Mailing Address - Country:US
Mailing Address - Phone:903-949-1051
Mailing Address - Fax:
Practice Address - Street 1:6306 WINDCREST DR APT 1733
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3028
Practice Address - Country:US
Practice Address - Phone:903-949-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X, 171M00000X
TX11894101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No171M00000XOther Service ProvidersCase Manager/Care Coordinator