Healthcare Provider Details

I. General information

NPI: 1699882449
Provider Name (Legal Business Name): ANIKA M KELSO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 04/19/2025
Certification Date: 04/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 LUISA ST STE 5A
SANTA FE NM
87505-4091
US

IV. Provider business mailing address

PO BOX 6623
SANTA FE NM
87502-6623
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-6868
  • Fax: 505-926-0906
Mailing address:
  • Phone: 505-795-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: