MEDICARE: MS. ELAINE BULLOCK KELLY MSW

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	6801074848	MI
2	104100000X	Social Worker	6801074848	MI

General Provider Information

NPI Number	:	1801993159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELAINE BULLOCK KELLY MSW

Provider Business Mailing Address
First Line	:	9203 MARNE ROAD - BATTLEMIND CENTER-SRU
Second Line	:	MARTIN ARMY COMMUNTIY HOSPITAL
City	:	FT. MOORE
State	:	GA
Zip	:	31905
Country	:	US
Telephone Number	:	706-544-4339
Fax Number	:	706-544-4236

Provider Business Practice Location Address
First Line	:	BUILDING 9203 MARNE ROAD
Second Line	:	MARTIN ARMY COMMUNTIY HOSPITAL
City	:	FT. MOORE
State	:	GA
Zip	:	31905
Country	:	US
Telephone Number	:	706-544-4339
Fax Number	:	706-544-4236

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/04/2024

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