Provider Demographics
NPI:1316560352
Name:WILHELM, KELLY L (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WILHELM
Suffix:
Gender:F
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-7422
Mailing Address - Fax:
Practice Address - Street 1:1912 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4736
Practice Address - Country:US
Practice Address - Phone:419-502-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171027101YA0400X
OH175378101YA0400X
OHS.2106471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty