Provider Demographics
NPI:1700390945
Name:WILSON, KATELYN (BCBA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 BARDSTOWN RD STE 15
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1333
Mailing Address - Country:US
Mailing Address - Phone:502-618-3334
Mailing Address - Fax:502-709-9892
Practice Address - Street 1:1250 BARDSTOWN RD STE 15
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1333
Practice Address - Country:US
Practice Address - Phone:502-618-3334
Practice Address - Fax:502-709-9892
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175231106E00000X
KY243621103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst