Provider Demographics
NPI:1326792391
Name:WILSON, COREY KAREEN
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:KAREEN
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:PO BOX 1485
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1485
Mailing Address - Country:US
Mailing Address - Phone:973-289-7813
Mailing Address - Fax:
Practice Address - Street 1:908 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3706
Practice Address - Country:US
Practice Address - Phone:973-289-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services