Provider Demographics
NPI:1780929547
Name:WILLMOTT, KELLY (LADC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILLMOTT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ERLANDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:16221 MAIN AVE SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1777
Mailing Address - Country:US
Mailing Address - Phone:952-440-6038
Mailing Address - Fax:952-440-6037
Practice Address - Street 1:16221 MAIN AVE SE
Practice Address - Street 2:SUITE 102
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1777
Practice Address - Country:US
Practice Address - Phone:952-440-6038
Practice Address - Fax:952-440-6037
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302238101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)