Provider Demographics
NPI:1912113184
Name:WILEY, KELLY PONDER (LMFTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:PONDER
Last Name:WILEY
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 PINNACLE DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-3445
Mailing Address - Country:US
Mailing Address - Phone:828-265-0737
Mailing Address - Fax:
Practice Address - Street 1:895 STATE FARM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4917
Practice Address - Country:US
Practice Address - Phone:828-262-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5057A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist