Provider Demographics
NPI:1730057464
Name:WILSON, KATELYNN RICHEY
Entity type:Individual
Prefix:
First Name:KATELYNN
Middle Name:RICHEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7603 GENESTA AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-2135
Mailing Address - Country:US
Mailing Address - Phone:818-277-6026
Mailing Address - Fax:
Practice Address - Street 1:11425 MOORPARK ST
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91602-2009
Practice Address - Country:US
Practice Address - Phone:310-920-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician