Basic Information
| Provider Information | |||||||||
| NPI: | 1710306097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | RAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2026 POINSETTIA ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927062922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145996473 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2101 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927054007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145423581 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 04/15/2014 | ||||||||
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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 | 101YA0400X | W0408271804 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.