Individual
KELLY JEAN BAULT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1800 OLD WEST MAIN ST APT 204, CARBONDALE, IL 62901-2165
(815) 343-2776
Mailing address
1800 OLD WEST MAIN ST APT 204, CARBONDALE, IL 62901-2165
(815) 343-2776
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Enumeration date
07/03/2011
Last updated
07/03/2011
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