Provider Demographics
NPI:1114225919
Name:WILSON, EMILY J (PT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:J
Other - Last Name:SIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:422 STUART AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3220
Mailing Address - Country:US
Mailing Address - Phone:989-330-0396
Mailing Address - Fax:
Practice Address - Street 1:810 W KILGORE RD STE 6
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3601
Practice Address - Country:US
Practice Address - Phone:269-366-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO150900039Medicare PIN