Provider Demographics
NPI:1982089371
Name:DARMOCHWAL, KELSEY (MS)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:DARMOCHWAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 W JEFFERSON BLVD # 220
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-267-0234
Mailing Address - Fax:260-264-6770
Practice Address - Street 1:2420 N COLISEUM BLVD STE 212
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3139
Practice Address - Country:US
Practice Address - Phone:260-267-0234
Practice Address - Fax:260-264-6770
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003938A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300068197Medicaid