Basic Information
| Provider Information | |||||||||
| NPI: | 1689130981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELSO | ||||||||
| FirstName: | STACEY | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 SAINT AUGUSTINE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291506008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144779214 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 SAINT AUGUSTINE DR | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291506008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144779214 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2019 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5270 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.