Provider Demographics
NPI:1326352881
Name:KNUTSON, KELLY JO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JO
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1770 SOUTH RANDALL ROAD
Mailing Address - Street 2:STE: A # 179
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-0603
Mailing Address - Country:US
Mailing Address - Phone:309-313-3789
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD
Practice Address - Street 2:STE 102
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6071
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-588-4115
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL071.007927103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical