Provider Demographics
NPI:1568067742
Name:WILSON, KELSEY LEIGH (RBT)
Entity Type:Individual
Prefix:MISS
First Name:KELSEY
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8891 ONEAL WOODS CT SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-8919
Mailing Address - Country:US
Mailing Address - Phone:616-240-9007
Mailing Address - Fax:
Practice Address - Street 1:1260 BUTH DR NE
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9501
Practice Address - Country:US
Practice Address - Phone:616-279-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-131150106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699272948OtherEMPLOYERS NPI