Provider Demographics
NPI:1275655276
Name:WILSON, KRISTIN LYNNETTE MAUCK (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LYNNETTE MAUCK
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 MANGROVE WAY
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3533
Mailing Address - Country:US
Mailing Address - Phone:540-793-1845
Mailing Address - Fax:
Practice Address - Street 1:1390 KING TREE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1401
Practice Address - Country:US
Practice Address - Phone:937-278-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT. 006762225X00000X
VA0119004314225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist