Healthcare Provider Details

I. General information

NPI: 1801993159
Provider Name (Legal Business Name): ELAINE BULLOCK KELLY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/04/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 9203 MARNE ROAD MARTIN ARMY COMMUNTIY HOSPITAL
FT. MOORE GA
31905
US

IV. Provider business mailing address

9203 MARNE ROAD - BATTLEMIND CENTER-SRU MARTIN ARMY COMMUNTIY HOSPITAL
FT. MOORE GA
31905
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-4339
  • Fax: 706-544-4236
Mailing address:
  • Phone: 706-544-4339
  • Fax: 706-544-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801074848
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801074848
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: