Provider Demographics
NPI:1487200598
Name:KELSEY, BOB (LADAC, LPN, EMT)
Entity Type:Individual
Prefix:MR
First Name:BOB
Middle Name:
Last Name:KELSEY
Suffix:
Gender:M
Credentials:LADAC, LPN, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 PREAKNESS DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5612
Mailing Address - Country:US
Mailing Address - Phone:931-319-7553
Mailing Address - Fax:
Practice Address - Street 1:115 W MARKET ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37166-1725
Practice Address - Country:US
Practice Address - Phone:931-319-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)