Provider Demographics
NPI:1306258736
Name:WILSON, KAITLAN
Entity type:Individual
Prefix:
First Name:KAITLAN
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 1:7361 ELBENS LN SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-5066
Mailing Address - Country:US
Mailing Address - Phone:704-526-7640
Mailing Address - Fax:
Practice Address - Street 1:140 CABARRUS AVE W
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-5150
Practice Address - Country:US
Practice Address - Phone:704-239-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306258736Medicaid