Provider Demographics
NPI:1154312189
Name:KELSO, MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7251
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91359-7251
Mailing Address - Country:US
Mailing Address - Phone:805-379-9600
Mailing Address - Fax:805-495-6970
Practice Address - Street 1:325 E HILLCREST DR STE 115
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-7782
Practice Address - Country:US
Practice Address - Phone:805-379-9600
Practice Address - Fax:805-495-6970
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical