Provider Demographics
NPI:1851722482
Name:MAMMEN, KELSEY L (PPC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 CY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3571
Mailing Address - Country:US
Mailing Address - Phone:775-445-9127
Mailing Address - Fax:
Practice Address - Street 1:1607 CY AVE STE 102
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3571
Practice Address - Country:US
Practice Address - Phone:307-337-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-08
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0100X
WYPPC-1190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service