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General NPI Number Information
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NPI Number | 1346605714
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Entity Type | Individual
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Provider Name | KELLEY WILSON PH.D.
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Gender | Female
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Dates
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Enumeration Date | 12/29/2015
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Last Update Date | 05/13/2024
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Provider Practice Location Address
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Address Line | 310 STATE HIGHWAY 59 N
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City | SUMMERDALE
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State | AL
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Zip | 36580-3620
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Country | US
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Telephone | 251-979-5066
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Fax |
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Provider Business Mailing Address
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Address Line | 5750A SOUTHLAND DR
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City | MOBILE
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State | AL
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Zip | 36693-3316
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1992
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License Number State | AL
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