Provider Demographics
NPI:1649916487
Name:WUSTERBARTH, KELSI LOUISE (LBA)
Entity type:Individual
Prefix:MISS
First Name:KELSI
Middle Name:LOUISE
Last Name:WUSTERBARTH
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26217 48TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-6301
Mailing Address - Country:US
Mailing Address - Phone:253-439-9691
Mailing Address - Fax:
Practice Address - Street 1:4227 S MERIDIAN STE C422
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3603
Practice Address - Country:US
Practice Address - Phone:888-362-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61505555103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst