Provider Demographics
NPI:1033708904
Name:WILKERSON, LAUREN (PTA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5957
Mailing Address - Country:US
Mailing Address - Phone:972-268-1494
Mailing Address - Fax:
Practice Address - Street 1:1000 E MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-3331
Practice Address - Country:US
Practice Address - Phone:972-723-5005
Practice Address - Fax:972-723-5008
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2159648225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant