Provider Demographics
NPI:1164865028
Name:WILSHUSEN, KELLY (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILSHUSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3117
Mailing Address - Country:US
Mailing Address - Phone:310-977-1461
Mailing Address - Fax:
Practice Address - Street 1:746 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3117
Practice Address - Country:US
Practice Address - Phone:424-237-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-10
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA889371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical