Provider Demographics
NPI:1184204422
Name:LILLY, KELSEY (MS)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LILLY
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 1:1436 E SAVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-4078
Mailing Address - Country:US
Mailing Address - Phone:262-339-8433
Mailing Address - Fax:
Practice Address - Street 1:10930 W POTTER RD STE A
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3450
Practice Address - Country:US
Practice Address - Phone:262-200-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-47876OtherBEHAVIOR ANALYST CERTIFICATION BOARD