Provider Demographics
NPI:1487390886
Name:BOUCKAERT, KATELYN NICOLE (LLMSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:NICOLE
Last Name:BOUCKAERT
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 WASHINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5175
Mailing Address - Country:US
Mailing Address - Phone:989-928-3566
Mailing Address - Fax:989-391-9596
Practice Address - Street 1:1009 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-5705
Practice Address - Country:US
Practice Address - Phone:989-928-3566
Practice Address - Fax:989-391-9596
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511162331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical