Provider Demographics
NPI:1104246966
Name:SELF, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1543 COUNTY ROAD 3350
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-8162
Mailing Address - Country:US
Mailing Address - Phone:479-647-8063
Mailing Address - Fax:
Practice Address - Street 1:1543 COUNTY ROAD 3350
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-8162
Practice Address - Country:US
Practice Address - Phone:479-647-8063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator