Healthcare Provider Details

I. General information

NPI: 1568352466
Provider Name (Legal Business Name): KATHRYN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN MCDERMOTT

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 DOROTHY ST
EL CAJON CA
92019-3101
US

IV. Provider business mailing address

745 EL RANCHO DR
EL CAJON CA
92019-1141
US

V. Phone/Fax

Practice location:
  • Phone: 619-444-8270
  • Fax:
Mailing address:
  • Phone: 951-526-8507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTH-008547
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: