Healthcare Provider Details

I. General information

NPI: 1861797805
Provider Name (Legal Business Name): KELLY BOLINGER PSY.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY BOLINGER PSY.D., HSPP

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W. KILGORE AVE.
MUNCIE IN
47304-4810
US

IV. Provider business mailing address

3700 WEST KILGORE AVE.
MUNCIE IN
47304-4810
US

V. Phone/Fax

Practice location:
  • Phone: 765-289-5437
  • Fax: 765-213-5094
Mailing address:
  • Phone: 765-289-5437
  • Fax: 765-213-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043413
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: