Basic Information
| Provider Information | |||||||||
| NPI: | 1396179727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | M.ED., BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913674976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 8184490994 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 194TH ST SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254262761 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-13-14981 | WA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.