Provider Demographics
NPI:1285912204
Name:WILSON, KATHRYN RUTH (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:RUTH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:151 N SUNRISE AVE
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2924
Mailing Address - Country:US
Mailing Address - Phone:916-771-8255
Mailing Address - Fax:
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:SUITE 1105
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2924
Practice Address - Country:US
Practice Address - Phone:916-771-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3598235Z00000X
CA20735235Z00000X
MD06878235Z00000X
DCSLP000582235Z00000X
FLSA12159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist