Provider Demographics
NPI:1164566881
Name:MARY KELSO, PH.,D. INC
Entity Type:Organization
Organization Name:MARY KELSO, PH.,D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-379-9600
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:951-245-0309
Practice Address - Street 1:325 E HILLCREST DR
Practice Address - Street 2:STE 115
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5828
Practice Address - Country:US
Practice Address - Phone:805-379-9600
Practice Address - Fax:951-245-0309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10466103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty