Provider Demographics
NPI:1245571033
Name:WILSON, KALA LATRAL (PTA)
Entity Type:Individual
Prefix:
First Name:KALA
Middle Name:LATRAL
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LAURENS ST
Mailing Address - Street 2:
Mailing Address - City:JOANNA
Mailing Address - State:SC
Mailing Address - Zip Code:29351-1407
Mailing Address - Country:US
Mailing Address - Phone:864-923-5298
Mailing Address - Fax:
Practice Address - Street 1:100 JOSEPH WALKER DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6939
Practice Address - Country:US
Practice Address - Phone:803-796-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant