Provider Demographics
NPI:1467807420
Name:KELSO, DEVAN (LMP)
Entity Type:Individual
Prefix:MR
First Name:DEVAN
Middle Name:
Last Name:KELSO
Suffix:
Gender:M
Credentials:LMP
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 1451
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98071-1451
Mailing Address - Country:US
Mailing Address - Phone:208-553-1824
Mailing Address - Fax:
Practice Address - Street 1:12911 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7939
Practice Address - Country:US
Practice Address - Phone:253-277-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60369798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1296672OtherAMTA