Provider Demographics
NPI:1396106886
Name:KELSO, CHARLOTTE (EDS, LATC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:KELSO
Suffix:
Gender:F
Credentials:EDS, LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 RIDGELAND WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-4357
Mailing Address - Country:US
Mailing Address - Phone:571-332-9630
Mailing Address - Fax:
Practice Address - Street 1:2383 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3126
Practice Address - Country:US
Practice Address - Phone:678-676-1059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0025242255A2300X
VA01260003772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer