Healthcare Provider Details

I. General information

NPI: 1538526991
Provider Name (Legal Business Name): PATIENCE KELLY-WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1898 THE ALAMEDA SAN JOSE
SAN JOSE CA
95126-1733
US

IV. Provider business mailing address

499 LOMA ALTA AVE
LOS GATOS CA
95030-6227
US

V. Phone/Fax

Practice location:
  • Phone: 408-928-1700
  • Fax:
Mailing address:
  • Phone: 408-379-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: