Individual
DR. THERESA K KELSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSY.D
Contact information
Practice address
420 BOULEVARD, SUITE 208, MOUNTAIN LAKES, NJ 07046-1742
(973) 299-2888
(973) 299-2876
Mailing address
420 BOULEVARD, SUITE 208, MOUNTAIN LAKES, NJ 07046-1742
(973) 299-2888
(973) 299-2876
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
35S1002377
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
048786
VALUEOPTIONS IDENTIFIER
NJ
01
—
223688014
FEDERAL TAX IDENTIFICATIO
NJ
01
—
4514820
AETNA BEH. HEALTH
NJ
Enumeration date
10/24/2006
Last updated
07/08/2007
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