Provider Demographics
NPI:1689407983
Name:KELLEY, CHERESE DANIELLE
Entity type:Individual
Prefix:
First Name:CHERESE
Middle Name:DANIELLE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27003 HIDDEN ROCK CT
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-6783
Mailing Address - Country:US
Mailing Address - Phone:210-262-9902
Mailing Address - Fax:
Practice Address - Street 1:27003 HIDDEN ROCK CT
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-6783
Practice Address - Country:US
Practice Address - Phone:210-262-9902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YM0800X
TX96164101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health