Healthcare Provider Details

I. General information

NPI: 1760992846
Provider Name (Legal Business Name): KELSEY L KOFOID RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

IV. Provider business mailing address

180 SIERRA COLLEGE DR
GRASS VALLEY CA
95945-5768
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-9541
  • Fax:
Mailing address:
  • Phone: 530-273-9541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1255800617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: