Provider Demographics
NPI:1124482328
Name:BOULDIN, KELLIE (LPC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 E LINCOLNWAY STE G
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5671
Mailing Address - Country:US
Mailing Address - Phone:307-514-1288
Mailing Address - Fax:
Practice Address - Street 1:2617 E LINCOLNWAY STE G
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5671
Practice Address - Country:US
Practice Address - Phone:307-514-1288
Practice Address - Fax:307-514-0979
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WYLPC-1727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor