Provider Demographics
NPI:1407023591
Name:WILSON, KELLY
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSY D
Mailing Address - Street 1:13875 HIGHWAY 13 S
Mailing Address - Street 2:SUITE 275
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2136
Mailing Address - Country:US
Mailing Address - Phone:612-237-3700
Mailing Address - Fax:952-226-7790
Practice Address - Street 1:13875 HIGHWAY 13 S
Practice Address - Street 2:SUITE 275
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2136
Practice Address - Country:US
Practice Address - Phone:612-237-3700
Practice Address - Fax:952-226-7790
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4438103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic