Active NPI
Kelley Wiederhold, LPC-ASSOCIATE
- Mental Health Counselor
- Bryan, TX
National Provider Identifier
1417763384
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 94350
- Practice address
- 1401 Sandia PLZ
Bryan, TX 77802-4356 - Phone
- (432) 940-9653
- NPI assigned
- Dec 5, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 94350 | TX | Primary |
Addresses
Primary practice location
1401 Sandia PLZ
Bryan, TX 77802-4356
Mailing address
1401 Sandia PLZ
Bryan, TX 77802-4356
Phone (432) 940-9653
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 94350 | TX | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1733356800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1733356800000",
"number": "1417763384",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1401 SANDIA PLZ",
"city": "BRYAN",
"state": "TX",
"postal_code": "778024356",
"telephone_number": "432-940-9653"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1401 SANDIA PLZ",
"city": "BRYAN",
"state": "TX",
"postal_code": "778024356",
"telephone_number": "432-940-9653"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIEDERHOLD",
"first_name": "KELLEY",
"credential": "LPC-ASSOCIATE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-12-05",
"last_updated": "2024-12-05",
"certification_date": "2024-12-05",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "TX",
"license": "94350",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bryan, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.