Healthcare Provider Details

I. General information

NPI: 1285280081
Provider Name (Legal Business Name): KELSEY ROSS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY LEWIS

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N COURT ST
WAYNE WV
25570-1141
US

IV. Provider business mailing address

175 SECRET HOLLOW LN
KENOVA WV
25530-7624
US

V. Phone/Fax

Practice location:
  • Phone: 304-272-5116
  • Fax:
Mailing address:
  • Phone: 304-633-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberE9R143400202
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: