Healthcare Provider Details

I. General information

NPI: 1629751169
Provider Name (Legal Business Name): KELSEY BLAIR EIDSON LPC, R-DMT, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W 51ST ST UNIT 1
AUSTIN TX
78756-2659
US

IV. Provider business mailing address

1310 S 1ST ST STE 200B
AUSTIN TX
78704-3061
US

V. Phone/Fax

Practice location:
  • Phone: 512-201-4501
  • Fax:
Mailing address:
  • Phone: 210-882-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number89696
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: