Provider Demographics
NPI:1508047754
Name:KELLY WILDER-WILLIS, PHD LLC
Entity Type:Organization
Organization Name:KELLY WILDER-WILLIS, PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WILDER-WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:732-618-4950
Mailing Address - Street 1:PO BOX 8264
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-8264
Mailing Address - Country:US
Mailing Address - Phone:732-618-4950
Mailing Address - Fax:
Practice Address - Street 1:51 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2333
Practice Address - Country:US
Practice Address - Phone:732-618-4950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00446400103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty