Provider Demographics
NPI:1992858682
Name:KELLY, NANCY W (PHD, LCSW)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-4520
Mailing Address - Country:US
Mailing Address - Phone:512-458-4646
Mailing Address - Fax:
Practice Address - Street 1:4103 MARATHON BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3719
Practice Address - Country:US
Practice Address - Phone:512-458-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX308341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical