Provider Demographics
NPI:1114518024
Name:FOSTER, KELLSIE M
Entity Type:Individual
Prefix:
First Name:KELLSIE
Middle Name:M
Last Name:FOSTER
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 1:150 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1141
Mailing Address - Country:US
Mailing Address - Phone:330-394-6342
Mailing Address - Fax:330-394-6029
Practice Address - Street 1:960 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2722
Practice Address - Country:US
Practice Address - Phone:330-989-5091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21871801101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool