Provider Demographics
NPI:1801528195
Name:WILSON, KATHERINE CECILIA
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:CECILIA
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 1:10097 MANCHESTER RD STE 102A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1828
Mailing Address - Country:US
Mailing Address - Phone:314-394-1911
Mailing Address - Fax:
Practice Address - Street 1:12255 DEPAUL DRIVE
Practice Address - Street 2:860
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2515
Practice Address - Country:US
Practice Address - Phone:314-394-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program