Basic Information
| Provider Information | |||||||||
| NPI: | 1578670998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHR | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 W.BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127072782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2403 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787047534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127072782 | ||||||||
| FaxNumber: | 5127072783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 30541 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 029372202 | 05 | TX | MEDICAID |