Provider Demographics
NPI:1992497499
Name:WILSON, KASEY
Entity type:Individual
Prefix:
First Name:KASEY
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 1:7592 METROPOLITAN DR STE 404
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4428
Mailing Address - Country:US
Mailing Address - Phone:619-376-6653
Mailing Address - Fax:
Practice Address - Street 1:7592 METROPOLITAN DR STE 404
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4428
Practice Address - Country:US
Practice Address - Phone:619-376-6653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB932091106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician