Provider Demographics
NPI:1508233610
Name:CROWTHER, KELSON (MA)
Entity Type:Individual
Prefix:
First Name:KELSON
Middle Name:
Last Name:CROWTHER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-3535
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:1151 N ADAIR ST
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-8900
Practice Address - Country:US
Practice Address - Phone:503-359-5564
Practice Address - Fax:503-357-4371
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10906779-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist