Provider Demographics
NPI:1568812832
Name:BOLGER, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOLGER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 1/2 CAMP ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-2535
Mailing Address - Country:US
Mailing Address - Phone:504-452-7478
Mailing Address - Fax:
Practice Address - Street 1:3517 CAMP ST
Practice Address - Street 2:1/2
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-2535
Practice Address - Country:US
Practice Address - Phone:504-452-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical