Basic Information
| Provider Information | |||||||||
| NPI: | 1104276922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLSON | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 C MICHAEL DAVENPORT BLVD STE 2 | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 406014481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028750561 | ||||||||
| FaxNumber: | 5028450570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2016 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 241632 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.