Healthcare Provider Details

I. General information

NPI: 1225978133
Provider Name (Legal Business Name): KAITLYN AUTUMN WILSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 OAK PARK BLVD
PLEASANT HILL CA
94523-4601
US

IV. Provider business mailing address

812 SE 48TH AVE
PORTLAND OR
97215-1724
US

V. Phone/Fax

Practice location:
  • Phone: 925-935-6630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310334
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number65866
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: