Provider Demographics
NPI:1720791221
Name:KELSO, LARA CHRISTINE (LPC)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:CHRISTINE
Last Name:KELSO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12138 FOXWOODS DR
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-3279
Mailing Address - Country:US
Mailing Address - Phone:314-608-1659
Mailing Address - Fax:
Practice Address - Street 1:10306 BUSINESS 21
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-5712
Practice Address - Country:US
Practice Address - Phone:636-797-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017041276101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017041276OtherLPC