Provider Demographics
NPI:1811103955
Name:KELSO, LISA (MS, MFT, LADC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:MS, MFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 BRONCO RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-3104
Mailing Address - Country:US
Mailing Address - Phone:702-521-6248
Mailing Address - Fax:
Practice Address - Street 1:601 N PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-2408
Practice Address - Country:US
Practice Address - Phone:702-455-5688
Practice Address - Fax:702-455-0185
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01143-L101YA0400X
NV0978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist