Provider Demographics
NPI:1114484052
Name:WILSON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 AMERICAN AVE
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4023
Mailing Address - Country:US
Mailing Address - Phone:610-644-6464
Mailing Address - Fax:
Practice Address - Street 1:400 FRANKLIN AVE STE 240
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-5137
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health