Provider Demographics
NPI:1104003870
Name:WILSON, ELLEN MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 DUSS AVE
Mailing Address - Street 2:
Mailing Address - City:AMBRIDGE
Mailing Address - State:PA
Mailing Address - Zip Code:15003-2060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 DUSS AVE
Practice Address - Street 2:
Practice Address - City:AMBRIDGE
Practice Address - State:PA
Practice Address - Zip Code:15003-2060
Practice Address - Country:US
Practice Address - Phone:724-266-2833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0041212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer