Healthcare Provider Details

I. General information

NPI: 1134440613
Provider Name (Legal Business Name): KATHERINE L. WILSON PSY. D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 08/19/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 VISTA SIERRA DR
ANTELOPE CA
95843-4610
US

IV. Provider business mailing address

PO BOX 8803
CITRUS HEIGHTS CA
95621-8803
US

V. Phone/Fax

Practice location:
  • Phone: 916-715-9069
  • Fax:
Mailing address:
  • Phone: 916-715-9069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30173
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: