Healthcare Provider Details

I. General information

NPI: 1730377508
Provider Name (Legal Business Name): KELVIN T BAILEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 TROJAN TRAIL
GLASGOW KY
42141-2214
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 844-435-0900
  • Fax: 270-858-4029
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4993
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: