Individual
KELLY WILLMOTT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LADC
Contact information
Practice address
16221 MAIN AVE SE, SUITE 102, PRIOR LAKE, MN 55372-1777
(952) 440-6038
(952) 440-6037
Mailing address
16221 MAIN AVE SE, SUITE 102, PRIOR LAKE, MN 55372-1777
(952) 440-6038
(952) 440-6037
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
302238
MN
Other
Enumeration date
12/05/2012
Last updated
12/05/2012
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