Provider Demographics
NPI:1861797805
Name:BOLINGER, KELLY (PSYD, HSPP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:BOLINGER
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BOLINGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD, HSPP
Mailing Address - Street 1:3700 WEST KILGORE AVE.
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4810
Mailing Address - Country:US
Mailing Address - Phone:765-289-5437
Mailing Address - Fax:765-213-5094
Practice Address - Street 1:3700 W. KILGORE AVE.
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4810
Practice Address - Country:US
Practice Address - Phone:765-289-5437
Practice Address - Fax:765-213-5094
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IN20043413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional