Provider Demographics
NPI:1043475452
Name:WILSON, DAVID OLIN (COTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:OLIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WINDY HILL DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-2862
Mailing Address - Country:US
Mailing Address - Phone:765-477-7791
Mailing Address - Fax:765-474-2986
Practice Address - Street 1:300 WINDY HILL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-2862
Practice Address - Country:US
Practice Address - Phone:765-477-7791
Practice Address - Fax:765-474-2986
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000495A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant