Provider Demographics
NPI:1225390263
Name:WILSON, CATHERINE
Entity Type:Individual
Prefix:MISS
First Name:CATHERINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1150 STARLING WAY
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6347
Mailing Address - Country:US
Mailing Address - Phone:321-543-8566
Mailing Address - Fax:
Practice Address - Street 1:7341 OFFICE PARK PL STE 107
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8280
Practice Address - Country:US
Practice Address - Phone:321-759-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10164103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst