Provider Demographics
NPI:1326581299
Name:WILSON, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:UPPERCO
Mailing Address - State:MD
Mailing Address - Zip Code:21155-9746
Mailing Address - Country:US
Mailing Address - Phone:410-429-1906
Mailing Address - Fax:
Practice Address - Street 1:7700 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7513
Practice Address - Country:US
Practice Address - Phone:410-821-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02387224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant