Provider Demographics
NPI:1063051308
Name:WILSON, KELLY SEVIN (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SEVIN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SEVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6941 POPLAR WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-6484
Mailing Address - Country:US
Mailing Address - Phone:239-896-4842
Mailing Address - Fax:
Practice Address - Street 1:2301 ELDORADO PKWY STE 150
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-1856
Practice Address - Country:US
Practice Address - Phone:469-215-0314
Practice Address - Fax:469-701-0909
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY106H00000X
TN106H00000X
TX202509106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist