Healthcare Provider Details

I. General information

NPI: 1811456874
Provider Name (Legal Business Name): KELLI WALDRON MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E LONGVIEW DR STE C
APPLETON WI
54911-2102
US

IV. Provider business mailing address

420 E LONGVIEW DR STE C
APPLETON WI
54911-2102
US

V. Phone/Fax

Practice location:
  • Phone: 920-815-3355
  • Fax: 920-239-6067
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: