| Doctor Name: | DR. KELLY WILSON |
| NPI Number: | 1407023591 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | LP4438 |
| Business Practice Address: | 13875 Highway 13 S Suite 275 Savage, MN - 553782136 |
| Business Phone Number: | 6122373700 |
| Business Fax Number: | 9522267790 |
| Mailing Address: | 13875 Highway 13 S, Suite 275 SAVAGE |
| State: | MN |
| Postal Code: | 553782136 |
| Phone Number: | 6122373700 |
| Fax Number: | 9522267790 |
| NPI Enumeration Date: | 05/08/2008 |
| NPI Last Update Date: | 05/08/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TF0200X |
| License Number: | LP4438 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Forensic |
| Taxonomy Definition: | |