Provider Demographics
NPI:1710737812
Name:WILSON, KALEB (MT)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 1/2 W PEDREGOSA ST APT C
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-5607
Mailing Address - Country:US
Mailing Address - Phone:510-388-9062
Mailing Address - Fax:
Practice Address - Street 1:311 1/2 W PEDREGOSA ST APT C
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-5607
Practice Address - Country:US
Practice Address - Phone:510-388-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93002225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist