Provider Demographics
NPI:1215403670
Name:GONZALEZ, KELSEY L
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
Last Name:GONZALEZ
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 1:1104 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-4969
Mailing Address - Country:US
Mailing Address - Phone:870-421-4816
Mailing Address - Fax:
Practice Address - Street 1:1310 BRADLEY DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2730
Practice Address - Country:US
Practice Address - Phone:870-424-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AR373H00000X
AR1-24-73061103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist