MEDICARE: MRS. GAY S KELSO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	37181	TX

General Provider Information

NPI Number	:	1962611459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GAY S KELSO LCSW

Provider Business Mailing Address
First Line	:	5751 PARK VISTA CIRCLE
Second Line	:	SUITE 101
City	:	KELLER
State	:	TX
Zip	:	76244-5607
Country	:	US
Telephone Number	:	817-812-2880
Fax Number	:	817-812-3096

Provider Business Practice Location Address
First Line	:	5751 PARK VISTA CIRCLE
Second Line	:	SUITE 101
City	:	KELLER
State	:	TX
Zip	:	76244-5607
Country	:	US
Telephone Number	:	817-812-2880
Fax Number	:	817-812-3096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	06/04/2015

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