Provider Demographics
NPI:1902345416
Name:WILSON, KELLY KENDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KENDRA
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:614 E EMMA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4469
Mailing Address - Country:US
Mailing Address - Phone:479-751-7417
Mailing Address - Fax:479-751-4898
Practice Address - Street 1:3162 W MARTIN LUTHER KING BLVD STE 13-14
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7679
Practice Address - Country:US
Practice Address - Phone:479-935-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8293-M1041C0700X
AR8293-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical