Provider Demographics
NPI:1326172305
Name:WILSON, MARIA (PT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 CHATTOOGA RD
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-3384
Mailing Address - Country:US
Mailing Address - Phone:864-587-7119
Mailing Address - Fax:
Practice Address - Street 1:355 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2537
Practice Address - Country:US
Practice Address - Phone:864-595-4225
Practice Address - Fax:864-595-4821
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist