Provider Demographics
NPI:1225854086
Name:TARGOSZ, KELSEY J (MS PPS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:J
Last Name:TARGOSZ
Suffix:
Gender:F
Credentials:MS PPS
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:J
Other - Last Name:POTORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 AL TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:S LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-4502
Mailing Address - Country:US
Mailing Address - Phone:530-543-2371
Mailing Address - Fax:
Practice Address - Street 1:MEYERS ELEMENTARY SCHOOL
Practice Address - Street 2:1095 E SAN BERNARDINO AVE
Practice Address - City:S LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-5235
Practice Address - Country:US
Practice Address - Phone:530-543-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YS0200X
CA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool