1558015826 NPI number — KACIE BODELL LCSW

Table of content: KACIE BODELL LCSW (NPI 1558015826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558015826 NPI number — KACIE BODELL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODELL
Provider First Name:
KACIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIDWELL
Provider Other First Name:
KACIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558015826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 BUTLER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSBURG
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25405-9991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-263-0811
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 BUTLER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSBURG
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25405-9991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-263-0811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  CW021581 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)