Provider Demographics
NPI:1114391521
Name:SMALL, KELSEA
Entity type:Individual
Prefix:
First Name:KELSEA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 S 190TH AVENUE PLZ APT 2370
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-5870
Mailing Address - Country:US
Mailing Address - Phone:402-310-5713
Mailing Address - Fax:
Practice Address - Street 1:130 E 9TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-4101
Practice Address - Country:US
Practice Address - Phone:402-727-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE103TS0200X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101Y00000XBehavioral Health & Social Service ProvidersCounselor