Provider Demographics
NPI:1891306023
Name:WEGNER, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WEGNER
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 1:3305 ASHLAR PT APT 304
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4277
Mailing Address - Country:US
Mailing Address - Phone:518-522-4296
Mailing Address - Fax:
Practice Address - Street 1:3305 ASHLAR PT APT 304
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4277
Practice Address - Country:US
Practice Address - Phone:518-522-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician