Provider Demographics
NPI:1235895319
Name:WILSON, BRIAN MITCHELL (OTR)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MITCHELL
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 W ST LUKES DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7912
Mailing Address - Country:US
Mailing Address - Phone:469-585-5771
Mailing Address - Fax:
Practice Address - Street 1:9850 W ST LUKES DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:469-585-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2031225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist