Healthcare Provider Details

I. General information

NPI: 1992177968
Provider Name (Legal Business Name): KELLY STANLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 N MARTIN LUTHER KING JR BLVD
WACO TX
76704-1438
US

IV. Provider business mailing address

1600 PROVIDENCE DR
WACO TX
76707-2261
US

V. Phone/Fax

Practice location:
  • Phone: 254-313-5000
  • Fax: 254-313-5099
Mailing address:
  • Phone: 254-313-4200
  • Fax: 254-313-4549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number56866
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: