Provider Demographics
NPI:1619583366
Name:ULLRICH, KELSEY (MA, LMHC, CYT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:ULLRICH
Suffix:
Gender:F
Credentials:MA, LMHC, CYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 ALEJANDRO STREET
Mailing Address - Street 2:GUEST HOUSE
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501
Mailing Address - Country:US
Mailing Address - Phone:901-230-0241
Mailing Address - Fax:
Practice Address - Street 1:409 ALEJANDRO STREET
Practice Address - Street 2:GUEST HOUSE
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-8750
Practice Address - Country:US
Practice Address - Phone:901-230-0241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0203601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health