Healthcare Provider Details

I. General information

NPI: 1942845862
Provider Name (Legal Business Name): KELSEY BAUMAN CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 E DESERT LN
PHOENIX AZ
85042-6916
US

IV. Provider business mailing address

2148 E DESERT LN
PHOENIX AZ
85042-6916
US

V. Phone/Fax

Practice location:
  • Phone: 623-210-2803
  • Fax:
Mailing address:
  • Phone: 623-210-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number87308
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: