Provider Demographics
NPI:1649764309
Name:BOLIBRZUCH, KYLEE WAYNETTE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KYLEE
Middle Name:WAYNETTE
Last Name:BOLIBRZUCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15856 BAXTER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8354
Mailing Address - Country:US
Mailing Address - Phone:619-886-9711
Mailing Address - Fax:
Practice Address - Street 1:3027 SAN DIEGO RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-493-8632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool