Provider Demographics
NPI:1245478064
Name:KELSO, LAUREL C (LCSW)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:C
Last Name:KELSO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:
Practice Address - Street 1:7191 WAGNER WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-0115
Practice Address - Country:US
Practice Address - Phone:253-514-8076
Practice Address - Fax:253-514-8078
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000075241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00007524OtherPROFESSIONAL LICENSE