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General NPI Number Information
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NPI Number | 1528619160
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Entity Type | Individual
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Provider Name | MRS. KELLY ANN WILSON
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Gender | Female
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Dates
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Enumeration Date | 09/25/2019
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 760 MOUNTAIN VIEW ST
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City | ALTADENA
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State | CA
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Zip | 91001-4996
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Country | US
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Telephone | 626-798-6793
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Fax |
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Provider Business Mailing Address
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Address Line | 867 N FAIR OAKS AVE
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City | PASADENA
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State | CA
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Zip | 91103-3050
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Country | US
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Telephone | 626-798-6793
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 104732
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 104732
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License Number State | CA
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