Provider Demographics
NPI:1407442411
Name:WILLETT, KELSEY JO
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JO
Last Name:WILLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RICHWOOD RD APT A1
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:KY
Mailing Address - Zip Code:40045-8232
Mailing Address - Country:US
Mailing Address - Phone:502-663-1671
Mailing Address - Fax:
Practice Address - Street 1:203 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-2454
Practice Address - Country:US
Practice Address - Phone:812-220-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)