Provider Demographics
NPI:1174565121
Name:KELLEY, DAVID B (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W PRAIRIE LEA ST
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-2555
Mailing Address - Country:US
Mailing Address - Phone:512-398-4896
Mailing Address - Fax:512-398-4896
Practice Address - Street 1:1010 FIR LN
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-2059
Practice Address - Country:US
Practice Address - Phone:512-398-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31422103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00000042MEOtherBCBS PRIVATE PRACTICE
TX1409500-02Medicaid
TX00244PMedicare UPIN