Provider Demographics
NPI:1740596279
Name:WILSON, KELLY R (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 HIGHLAND AVE
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1040
Mailing Address - Country:US
Mailing Address - Phone:650-906-6177
Mailing Address - Fax:
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 71
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:857-600-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-21
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9580103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical