Basic Information
| Provider Information | |||||||||
| NPI: | 1891233789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINCHELOE | ||||||||
| FirstName: | VANESSA | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 TAFT BLVD | ||||||||
| Address2: | 2 | ||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763084872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406911899 | ||||||||
| FaxNumber: | 9406913423 | ||||||||
| Practice Location | |||||||||
| Address1: | 4722 TAFT BLVD | ||||||||
| Address2: | 2 | ||||||||
| City: | WICHITA FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763084872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406911899 | ||||||||
| FaxNumber: | 9406913423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2017 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 37530 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.