Provider Demographics
NPI:1407511280
Name:WILSON, KELDON OLIVER
Entity Type:Individual
Prefix:
First Name:KELDON
Middle Name:OLIVER
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 RING RD S APT 6321
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1002
Mailing Address - Country:US
Mailing Address - Phone:517-213-3527
Mailing Address - Fax:
Practice Address - Street 1:2236 BROOK DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-2806
Practice Address - Country:US
Practice Address - Phone:269-492-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation