Provider Demographics
NPI:1174979231
Name:KELLY, AUSTIN NEEL (PSYD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:NEEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 SOUTH 31ST STREET
Practice Address - Street 2:MAILSTOP: MS-22-103E
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508
Practice Address - Country:US
Practice Address - Phone:254-725-3874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
TX39255103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program