Kelly Jo Knutson, PSY.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

071.007927 Issued in IL

Practice address

808 S Eldorado Rd
Ste 102
Bloomington, IL 61704-6071

Phone

(309) 706-3190

Fax

(309) 588-4115

NPI assigned

Jul 27, 2010

Last updated

Nov 19, 2021By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Interoperability endpoints

• Direct secure messaging: lifestancehealth.kellyknutson@146897.advancedmd-direct.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1280188800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1637280000000",
    "number": "1326352881",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1770 SOUTH RANDALL ROAD",
            "address_2": "STE: A # 179",
            "city": "GENEVA",
            "state": "IL",
            "postal_code": "601340603",
            "telephone_number": "309-313-3789"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "808 S ELDORADO RD",
            "address_2": "STE 102",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617046071",
            "telephone_number": "309-706-3190",
            "fax_number": "309-588-4115"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1770 S Randall Road",
            "address_2": "Ste: A # 179",
            "address_purpose": "LOCATION",
            "city": "Geneva",
            "state": "IL",
            "postal_code": "601344603",
            "country_code": "US",
            "telephone_number": "309-313-3789",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "14408 Woods Walk Ct",
            "address_purpose": "LOCATION",
            "city": "Midlothian",
            "state": "VA",
            "postal_code": "231122412",
            "country_code": "US",
            "telephone_number": "309-313-3789",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KNUTSON",
        "first_name": "KELLY",
        "middle_name": "JO",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2010-07-27",
        "last_updated": "2021-11-19",
        "certification_date": "2021-11-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071.007927",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lawrence Kneezel, M.D.
• Sarah J Knight
• Malissa J Knobloch
• Jason Knox
• Karlee Knudsen
• Jennifer Elizabeth Koch, PSY.D.
• Shawn M Koehler, O.D.
• Anne Metrick Koehne, DMD
• Kamri Koenig
• Pamela Koh

• Clinical Psychologist in Bloomington, IL
• Providers in Bloomington, IL by specialty
• Clinical Psychologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.