Healthcare Provider Details

I. General information

NPI: 1902726532
Provider Name (Legal Business Name): KELLY WILLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N 870 W STE 101-104
LOGAN UT
84321-6899
US

IV. Provider business mailing address

1239 N 400 E APT 1
LOGAN UT
84341-7508
US

V. Phone/Fax

Practice location:
  • Phone: 888-392-8642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: