Provider Demographics
NPI:1205841517
Name:BELL, KELLY BOUCHIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BOUCHIE
Last Name:BELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 OGLETHORPE PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3623
Mailing Address - Country:US
Mailing Address - Phone:912-353-7699
Mailing Address - Fax:912-353-9879
Practice Address - Street 1:107 OGLETHORPE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3623
Practice Address - Country:US
Practice Address - Phone:902-353-7699
Practice Address - Fax:912-925-9879
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW00037431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06081209Medicaid
MS800000252Medicare ID - Type Unspecified