Provider Demographics
NPI:1013533652
Name:BAUERLE, KELSEA N
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:N
Last Name:BAUERLE
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 1:54 TOM TEAGUE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-5991
Mailing Address - Country:US
Mailing Address - Phone:770-668-6675
Mailing Address - Fax:
Practice Address - Street 1:54 TOM TEAGUE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-5991
Practice Address - Country:US
Practice Address - Phone:770-668-6675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-124576106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician