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General NPI Number Information
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NPI Number | 1164566881
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Entity Type | Organization
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Legal Business Name | MARY KELSO, PH.,D. INC
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Dates
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Enumeration Date | 02/16/2007
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 325 E HILLCREST DR STE 115
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City | THOUSAND OAKS
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State | CA
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Zip | 91360-5828
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Country | US
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Telephone | 805-379-9600
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Fax | 951-245-0309
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Provider Business Mailing Address
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Address Line | PO BOX 7251
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City | WESTLAKE VILLAGE
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State | CA
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Zip | 91359-7251
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Country | US
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Telephone | 805-379-9600
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Fax | 951-245-0309
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. MARY KELSO
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Credential | PH.D.
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Telephone | 805-379-9600
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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 | PSY10466
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License Number State | CA
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