Basic Information
| Provider Information | |||||||||
| NPI: | 1346605714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750A SOUTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933316 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1015 MONTLIMAR DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366091713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514502250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2015 | ||||||||
| LastUpdateDate: | 12/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1992 | AL | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.