=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538792387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY BAILEY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2020
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 E GRAND AVE
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-368-8087
-----------------------------------------------------
Fax | 608-312-2061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2135 CANDI LN
-----------------------------------------------------
City | BELOIT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53511-7025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-295-4539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.022732
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CO13652
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 130921
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------