Provider Demographics
NPI:1558015826
Name:BODELL, KACIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:
Last Name:BODELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:
Other - Last Name:KIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:510 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9991
Mailing Address - Country:US
Mailing Address - Phone:304-263-0811
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9991
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW021581101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health