Provider Demographics
NPI:1245789858
Name:KELSO, SUSAN (LMT, EST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:LMT, EST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 CRANDON BLVD
Mailing Address - Street 2:B-104
Mailing Address - City:KEY BISCAYNE
Mailing Address - State:FL
Mailing Address - Zip Code:33149-2745
Mailing Address - Country:US
Mailing Address - Phone:305-365-9767
Mailing Address - Fax:
Practice Address - Street 1:1111 CRANDON BLVD
Practice Address - Street 2:B-104
Practice Address - City:KEY BISCAYNE
Practice Address - State:FL
Practice Address - Zip Code:33149
Practice Address - Country:US
Practice Address - Phone:305-365-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0014312225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist