Provider Demographics
NPI:1083797682
Name:KELSO, THERESA K (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:K
Last Name:KELSO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BOULEVARD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1742
Mailing Address - Country:US
Mailing Address - Phone:973-299-2888
Mailing Address - Fax:973-299-2876
Practice Address - Street 1:420 BOULEVARD
Practice Address - Street 2:SUITE 208
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1742
Practice Address - Country:US
Practice Address - Phone:973-299-2888
Practice Address - Fax:973-299-2876
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S1002377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ048786OtherVALUEOPTIONS IDENTIFIER
NJ223688014OtherFEDERAL TAX IDENTIFICATIO
NJ4514820OtherAETNA BEH. HEALTH
NJ048786OtherVALUEOPTIONS IDENTIFIER