Provider Demographics
NPI:1861420366
Name:KELLY, BONNIE JEANNE (LCSW)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:J
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:708 MOBJACK PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1957
Mailing Address - Country:US
Mailing Address - Phone:757-873-1958
Mailing Address - Fax:757-873-2143
Practice Address - Street 1:708 MOBJACK PL
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1957
Practice Address - Country:US
Practice Address - Phone:757-873-1958
Practice Address - Fax:757-873-2143
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040004831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2109871OtherMAMSI
VA86862OtherSENTARA
VA5359671OtherAETNA
VT331939OtherANTHEM BC/BS
VA008952914Medicaid
VA043493OtherVALUE OPTIONS