Provider Demographics
NPI:1851174650
Name:WILSON, KAITLYN NICHOLE (LPCC 14444)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:NICHOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPCC 14444
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 FRIARS RD STE 208
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1078
Mailing Address - Country:US
Mailing Address - Phone:540-229-0204
Mailing Address - Fax:
Practice Address - Street 1:5920 FRIARS RD STE 208
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1078
Practice Address - Country:US
Practice Address - Phone:858-215-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14444101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty