Provider Demographics
NPI:1407001720
Name:KELSO, SAMUEL CARY (AUD)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:CARY
Last Name:KELSO
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 ADA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4985
Mailing Address - Country:US
Mailing Address - Phone:501-327-3929
Mailing Address - Fax:501-329-3816
Practice Address - Street 1:2200 ADA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4985
Practice Address - Country:US
Practice Address - Phone:501-327-3929
Practice Address - Fax:501-329-3816
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA147237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter