Provider Demographics
NPI:1184077190
Name:KELSO, KENNETH BRYAN (LMFT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRYAN
Last Name:KELSO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:BRYAN
Other - Middle Name:
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:845 MCCAULEY WAY
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8336
Mailing Address - Country:US
Mailing Address - Phone:916-532-0074
Mailing Address - Fax:
Practice Address - Street 1:845 MCCAULEY WAY
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8336
Practice Address - Country:US
Practice Address - Phone:916-532-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT88603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist