Provider Demographics
NPI:1336989912
Name:KELLEY WILSON PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:KELLEY WILSON PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:251-551-9470
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533-0650
Mailing Address - Country:US
Mailing Address - Phone:251-551-9470
Mailing Address - Fax:
Practice Address - Street 1:25833 STATE HIGHWAY 181
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-6101
Practice Address - Country:US
Practice Address - Phone:251-551-9470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty