Provider Demographics
NPI:1609541820
Name:KINGSMORE, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KINGSMORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6010 HIDDEN VALLEY RD STE 115
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-4219
Practice Address - Country:US
Practice Address - Phone:855-501-1004
Practice Address - Fax:760-814-6094
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT136920106H00000X
CA153308106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist