Provider Demographics
NPI:1689130981
Name:KELSO, STACEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 SAINT AUGUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-6008
Mailing Address - Country:US
Mailing Address - Phone:614-477-9214
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:585 SAINT AUGUSTINE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-6008
Practice Address - Country:US
Practice Address - Phone:614-477-9214
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5270225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist