Provider Demographics
NPI:1114022928
Name:WILSON, JODIE (PT)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:RANGELEY
Mailing Address - State:ME
Mailing Address - Zip Code:04970-0569
Mailing Address - Country:US
Mailing Address - Phone:207-864-3303
Mailing Address - Fax:207-864-2969
Practice Address - Street 1:32 RAILROAD STREET
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:ME
Practice Address - Zip Code:04217-1367
Practice Address - Country:US
Practice Address - Phone:207-824-2193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT540225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
206507Medicare ID - Type Unspecified