Provider Demographics
NPI:1043862097
Name:KELSO, SHELBY LEE (APSW, SAC-IT)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEE
Last Name:KELSO
Suffix:
Gender:F
Credentials:APSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 ODANA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1129
Mailing Address - Country:US
Mailing Address - Phone:608-434-2646
Mailing Address - Fax:414-246-2524
Practice Address - Street 1:6314 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1129
Practice Address - Country:US
Practice Address - Phone:608-434-2646
Practice Address - Fax:414-246-2524
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
131572104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker