Provider Demographics
NPI:1265017800
Name:WILSON, DANIELLE KATHERINE (COTA/L)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:KATHERINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 INDIAN WELLS RD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4617
Mailing Address - Country:US
Mailing Address - Phone:575-437-1967
Mailing Address - Fax:575-437-3969
Practice Address - Street 1:1809 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4617
Practice Address - Country:US
Practice Address - Phone:575-437-1967
Practice Address - Fax:575-437-3969
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOTA4435224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant