Provider Demographics
NPI:1366804742
Name:KELLY, MARK RYAN (LPC, LCDC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RYAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3309
Mailing Address - Country:US
Mailing Address - Phone:361-576-4673
Mailing Address - Fax:
Practice Address - Street 1:403 E HILLJE ST
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-4503
Practice Address - Country:US
Practice Address - Phone:361-571-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional