Provider Demographics
NPI:1083965636
Name:KELSOE, ELIZABETH (COTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KELSOE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-7814
Mailing Address - Country:US
Mailing Address - Phone:812-604-7545
Mailing Address - Fax:
Practice Address - Street 1:3801 OLD BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3889
Practice Address - Country:US
Practice Address - Phone:812-882-1783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-23
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001556A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant