Provider Demographics
NPI:1093011595
Name:WILSON, BRAD C (DPT,ATC)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 A HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-250-5455
Mailing Address - Fax:601-250-5453
Practice Address - Street 1:1301 A HARRISON AVE
Practice Address - Street 2:PROFESSIONAL REHAB ASSOCIATES
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-250-5455
Practice Address - Fax:601-250-5453
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMSPT3350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1093011595Medicare UPIN