MEDICARE: RACHEL KELLY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW17480	FL
2	1041C0700X	Clinical Social Worker	CSW007289	GA

General Provider Information

NPI Number	:	1417530965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL KELLY LCSW

Provider Business Mailing Address
First Line	:	511 SILVER LAKE RD
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-6849
Country	:	US
Telephone Number	:	229-254-0661
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 SILVER LAKE RD
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-6849
Country	:	US
Telephone Number	:	229-254-0661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2021
Last Update Date	:	05/03/2021

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Directions to “ RACHEL KELLY LCSW” Practice Location

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