Provider Demographics
NPI:1154091221
Name:WILKERSON, OLIVIA GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:GRACE
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:DPT
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 1014
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1014
Mailing Address - Country:US
Mailing Address - Phone:732-855-9751
Mailing Address - Fax:732-855-9755
Practice Address - Street 1:1124 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1419
Practice Address - Country:US
Practice Address - Phone:908-233-1222
Practice Address - Fax:908-233-2021
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02041900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist