Provider Demographics
NPI:1952481400
Name:WILSON, KELLI LYNN (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:LYNN
Other - Last Name:WILSON-YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:1247 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:CLARENDON
Mailing Address - State:VT
Mailing Address - Zip Code:05759
Mailing Address - Country:US
Mailing Address - Phone:802-773-3620
Mailing Address - Fax:
Practice Address - Street 1:1247 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:CLARENDON
Practice Address - State:VT
Practice Address - Zip Code:05759
Practice Address - Country:US
Practice Address - Phone:802-773-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1000000042101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00068963OtherBCBS
VT1010469Medicaid