Provider Demographics
NPI:1447447479
Name:KELLY, VANESSA KAY (MS)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:KAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-4822
Mailing Address - Country:US
Mailing Address - Phone:361-661-1192
Mailing Address - Fax:
Practice Address - Street 1:204 E 1ST ST
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4822
Practice Address - Country:US
Practice Address - Phone:361-661-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
TX105926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126281721Medicaid