Provider Demographics
NPI:1184642571
Name:WILDER-WILLIS, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILDER-WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2333
Mailing Address - Country:US
Mailing Address - Phone:732-618-4950
Mailing Address - Fax:732-219-1910
Practice Address - Street 1:51 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2333
Practice Address - Country:US
Practice Address - Phone:732-618-4950
Practice Address - Fax:732-219-1910
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00857103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007058135Medicare PIN
RI709004399Medicare ID - Type UnspecifiedGROUP NUMBER
NJ119256Medicare PIN