Healthcare Provider Details

I. General information

NPI: 1871920546
Provider Name (Legal Business Name): BOBBI JAE KELSEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 WASHINGTON ST
MONTPELIER ID
83254-1423
US

IV. Provider business mailing address

1100 TORREY RD STE 100
FENTON MI
48430-3327
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-4464
  • Fax: 208-847-4251
Mailing address:
  • Phone: 208-847-4464
  • Fax: 208-847-4251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number17440
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-35444
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: