Provider Demographics
NPI:1972285294
Name:WILSON, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
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 1:25 LOFTY LN
Mailing Address - Street 2:
Mailing Address - City:MONTANA MINES
Mailing Address - State:WV
Mailing Address - Zip Code:26586-2700
Mailing Address - Country:US
Mailing Address - Phone:304-612-9592
Mailing Address - Fax:
Practice Address - Street 1:2025 WHITE OAKS BLVD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-5402
Practice Address - Country:US
Practice Address - Phone:304-612-9592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0986235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist