Healthcare Provider Details

I. General information

NPI: 1104731371
Provider Name (Legal Business Name): DESZANIQUE KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6807 EMMETT F LOWRY EXPRESSWAY FRONTAGE RD SUITE 105
TEXAS CITY TX
77591
US

IV. Provider business mailing address

6807 EMMETT F LOWRY EXPRESSWAY FRONTAGE RD SUITE 105
TEXAS CITY TX
77591
US

V. Phone/Fax

Practice location:
  • Phone: 409-229-4280
  • Fax: 866-416-2256
Mailing address:
  • Phone: 409-229-4280
  • Fax: 866-416-2256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1546689
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: