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General NPI Number Information
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NPI Number | 1033369699
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Entity Type | Organization
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Legal Business Name | T. K. KELSO, PSY.D, LLC
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Dates
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Enumeration Date | 09/19/2008
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Last Update Date | 12/29/2008
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Provider Practice Location Address
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Address Line | 420 BOULEVARD, SUITE 208
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City | MOUNTAIN LAKES
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State | NJ
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Zip | 07046-1742
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Country | US
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Telephone | 973-299-2888
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Fax | 973-299-2876
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Provider Business Mailing Address
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Address Line | 420 BOULEVARD, SUITE 208
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City | MOUNTAIN LAKES
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State | NJ
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Zip | 07046-1742
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Country | US
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Telephone | 973-299-2888
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Fax | 973-299-2876
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Authorized Official
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Title or Position | OWNER
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Name | DR. THERESA K KELSO
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Credential | PSY.D
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Telephone | 973-299-2888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 35S1002377
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License Number State | NJ
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