Healthcare Provider Details

I. General information

NPI: 1255177044
Provider Name (Legal Business Name): CAITLIN MICHELLE WILSON SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/02/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 JOE KOELSCH DR
LOCUST GROVE OK
74352
US

IV. Provider business mailing address

320 NE 4418
SALINA OK
74365-2472
US

V. Phone/Fax

Practice location:
  • Phone: 918-479-5243
  • Fax:
Mailing address:
  • Phone: 918-718-4558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number650
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: