Provider Demographics
NPI:1356436620
Name:KELSO, THERESA FORD (MSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:FORD
Last Name:KELSO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 4TH AVENUE E, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-6512
Mailing Address - Country:US
Mailing Address - Phone:360-786-9499
Mailing Address - Fax:360-786-0758
Practice Address - Street 1:2101 4TH AVENUE E, SUITE 200
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-6512
Practice Address - Country:US
Practice Address - Phone:360-786-9499
Practice Address - Fax:360-786-0758
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000043921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB13939Medicare ID - Type Unspecified