Provider Demographics
NPI:1194206599
Name:WILSON, SERENE (MSPT)
Entity Type:Individual
Prefix:MS
First Name:SERENE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4596 ADAMS DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-1311
Mailing Address - Country:US
Mailing Address - Phone:925-408-5856
Mailing Address - Fax:
Practice Address - Street 1:5099 COMMERCIAL CIR STE 205
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1292
Practice Address - Country:US
Practice Address - Phone:925-677-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist