Provider Demographics
NPI:1023441417
Name:KELSO, KATHERINE SUE (BCBA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUE
Last Name:KELSO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 LENNOX AVE APT 255
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3141
Mailing Address - Country:US
Mailing Address - Phone:818-720-5838
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2694
Practice Address - Country:US
Practice Address - Phone:323-422-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-13441103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst