Provider Demographics
NPI:1063827699
Name:WILSON, DEBORAH (PTA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:WILSON
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 1:12011 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-1402
Mailing Address - Country:US
Mailing Address - Phone:402-915-3201
Mailing Address - Fax:402-315-9994
Practice Address - Street 1:4951 CENTER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3251
Practice Address - Country:US
Practice Address - Phone:402-915-3201
Practice Address - Fax:402-315-9994
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1050225200000X
NE3343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant