Provider Demographics
NPI:1134875941
Name:KELSO, HEATHER L (CDCA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:KELSO
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E CENTER ST STE 301
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-4142
Mailing Address - Country:US
Mailing Address - Phone:740-796-8835
Mailing Address - Fax:
Practice Address - Street 1:333 E CENTER ST STE 301
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4142
Practice Address - Country:US
Practice Address - Phone:740-796-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OH186253101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health