Provider Demographics
NPI:1902454606
Name:WILSON, KAYLEE BREE
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:BREE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7433 RUTLEDGE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8306
Mailing Address - Country:US
Mailing Address - Phone:760-684-5296
Mailing Address - Fax:
Practice Address - Street 1:9333 BASELINE RD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1350
Practice Address - Country:US
Practice Address - Phone:909-755-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty