Healthcare Provider Details

I. General information

NPI: 1760266266
Provider Name (Legal Business Name): KELLY LYNN VERACRUZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 03/13/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S DUVAL ST
MATHIS TX
78368-2613
US

IV. Provider business mailing address

204 E 1ST ST
ALICE TX
78332-4822
US

V. Phone/Fax

Practice location:
  • Phone: 361-547-4121
  • Fax: 361-384-4254
Mailing address:
  • Phone: 361-664-0145
  • Fax: 361-664-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number82428
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: