Provider Demographics
NPI:1275847055
Name:WILSON, LORI JEAN (MS)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:JEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 DR. POUST ROAD
Mailing Address - Street 2:
Mailing Address - City:HUGHESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17737-0032
Mailing Address - Country:US
Mailing Address - Phone:570-584-6049
Mailing Address - Fax:570-584-6049
Practice Address - Street 1:58 NEITZ ROAD
Practice Address - Street 2:
Practice Address - City:NORTHUMBERLAND
Practice Address - State:PA
Practice Address - Zip Code:17857-0032
Practice Address - Country:US
Practice Address - Phone:570-473-8366
Practice Address - Fax:570-473-8280
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009496225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation