Provider Demographics
NPI:1164993986
Name:WILSON, SUE ELLEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2644 RIVA RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7427
Mailing Address - Country:US
Mailing Address - Phone:410-222-5000
Mailing Address - Fax:
Practice Address - Street 1:2644 RIVA RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7427
Practice Address - Country:US
Practice Address - Phone:410-222-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01740225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist