Provider Demographics
NPI:1093335358
Name:WILSON, DANIEL
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2096 E. 230 S.
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542
Mailing Address - Country:US
Mailing Address - Phone:812-309-3177
Mailing Address - Fax:
Practice Address - Street 1:3800 ELI PL
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-7436
Practice Address - Country:US
Practice Address - Phone:812-858-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002291A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant