Provider Demographics
NPI:1932363892
Name:BAULISCH, KELLY (LMHP, LPC, LADC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BAULISCH
Suffix:
Gender:F
Credentials:LMHP, LPC, LADC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3402
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:1490 N 16TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-4101
Practice Address - Country:US
Practice Address - Phone:402-827-0570
Practice Address - Fax:402-827-0577
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8951101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47082303526Medicaid