Healthcare Provider Details

I. General information

NPI: 1073372678
Provider Name (Legal Business Name): NICALONDRIA KELLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20008 CHAMPION FOREST DR STE 601
SPRING TX
77379-8696
US

IV. Provider business mailing address

14410 KERRICK VISTA LN
CONROE TX
77384-1514
US

V. Phone/Fax

Practice location:
  • Phone: 281-892-9986
  • Fax:
Mailing address:
  • Phone: 281-901-4043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number85258
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: