Healthcare Provider Details

I. General information

NPI: 1225576747
Provider Name (Legal Business Name): KELLY LAUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 FM 359 RD STE H
RICHMOND TX
77406-2023
US

IV. Provider business mailing address

1421 FM 359 RD STE H
RICHMOND TX
77406-2023
US

V. Phone/Fax

Practice location:
  • Phone: 281-232-1900
  • Fax:
Mailing address:
  • Phone: 281-232-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17784
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: