Provider Demographics
NPI:1144796699
Name:VEGA, KELSEY (LSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:AEON
Other - Middle Name:
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:340 E DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45419-1712
Mailing Address - Country:US
Mailing Address - Phone:937-272-8110
Mailing Address - Fax:
Practice Address - Street 1:8134 NEW LA GRANGE RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4677
Practice Address - Country:US
Practice Address - Phone:502-472-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802969104100000X
KY256742104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker