Provider Demographics
NPI:1558514125
Name:BELGARDE, KELLEY
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:
Last Name:BELGARDE
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 1:201 S WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2515
Mailing Address - Country:US
Mailing Address - Phone:574-234-2870
Mailing Address - Fax:574-232-2872
Practice Address - Street 1:201 S WILLIAM ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-2515
Practice Address - Country:US
Practice Address - Phone:574-234-2870
Practice Address - Fax:574-232-2872
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200898790Medicaid