Provider Demographics
NPI:1366552481
Name:KELZER, KENNETH JOHN (MSW LCSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:KELZER
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-2416
Mailing Address - Country:US
Mailing Address - Phone:415-897-2300
Mailing Address - Fax:415-883-4360
Practice Address - Street 1:1025 5TH STREET
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-2416
Practice Address - Country:US
Practice Address - Phone:415-897-2300
Practice Address - Fax:415-883-4360
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS46121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ72122ZMedicare ID - Type Unspecified