Healthcare Provider Details

I. General information

NPI: 1962345330
Provider Name (Legal Business Name): KAITLIN MULVANEY-WILSON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

8911 LAKEWOOD DR STE 29
WINDSOR CA
95492-7860
US

IV. Provider business mailing address

300 STONY POINT RD APT 145
SANTA ROSA CA
95401-5948
US

V. Phone/Fax

Practice location:
  • Phone: 602-579-0022
  • Fax:
Mailing address:
  • Phone: 602-579-0022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number28334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: