Provider Demographics
NPI:1316540172
Name:WILSON, MADISON KAYLEE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:KAYLEE
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11434 B AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11434 B AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2603
Practice Address - Country:US
Practice Address - Phone:530-863-8093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2025-04-24
Deactivation Date:2024-09-09
Deactivation Code:
Reactivation Date:2024-09-17
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X, 225400000X
CA172V00000X
CAMPSS-FBSENG175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist