Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | 1-21-47100 | TX |
NPI | 1003406554 |
---|---|
Provider Name | Traci Kelly |
First Address | Fort Worth, TX 76179-3225 |
Second Address | Fort Worth, TX 76179-3225 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2021 |
Last Update Date | 19/01/2021 |