Provider Demographics
NPI:1639767551
Name:WILLIAMSON, KELLY ALTON
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ALTON
Last Name:WILLIAMSON
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 1:2374 VALLEY VISTA RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 EMMANUEL WAY LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:KY
Practice Address - Zip Code:40176-5037
Practice Address - Country:US
Practice Address - Phone:310-560-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician