Provider Demographics
NPI:1003398306
Name:WILSON, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
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 1:1008 COLDIRON HTS
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:KY
Mailing Address - Zip Code:40806-8418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19101 N US HIGHWAY 119
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:KY
Practice Address - Zip Code:40823-8107
Practice Address - Country:US
Practice Address - Phone:606-589-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant