Provider Demographics
NPI:1083602064
Name:WILSON, KERRY G (MSPT)
Entity Type:Individual
Prefix:MISS
First Name:KERRY
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E STAR CT
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6704
Mailing Address - Country:US
Mailing Address - Phone:970-249-1646
Mailing Address - Fax:970-249-8899
Practice Address - Street 1:611 E STAR CT
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6704
Practice Address - Country:US
Practice Address - Phone:970-249-1646
Practice Address - Fax:970-249-8899
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPT-2447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64606511Medicaid