Healthcare Provider Details

I. General information

NPI: 1780807636
Provider Name (Legal Business Name): MS. KATHLEEN WILSON-PARISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CHERRY LN STE 115
MANTECA CA
95337-4398
US

IV. Provider business mailing address

1567 PURPLE MARTIN LN
MANTECA CA
95337-7906
US

V. Phone/Fax

Practice location:
  • Phone: 209-740-9944
  • Fax: 209-665-4032
Mailing address:
  • Phone: 209-740-9943
  • Fax: 209-665-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT50051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: