Provider Demographics
NPI:1851772156
Name:WILSON, KAITLIN M (PLMHP)
Entity Type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4650
Mailing Address - Country:US
Mailing Address - Phone:308-635-3171
Mailing Address - Fax:308-632-0137
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-3168
Practice Address - Country:US
Practice Address - Phone:970-522-4392
Practice Address - Fax:709-522-2217
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10544101YM0800X
CO0014713101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health