Provider Demographics
NPI:1346449493
Name:WILSON, AUDREY (CLMT MMP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CLMT MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COURTHOUSE LN
Mailing Address - Street 2:SUITE 13- REAR
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-1715
Mailing Address - Country:US
Mailing Address - Phone:978-996-3396
Mailing Address - Fax:978-677-7244
Practice Address - Street 1:2 COURTHOUSE LN
Practice Address - Street 2:SUITE 13- REAR
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-1715
Practice Address - Country:US
Practice Address - Phone:978-996-3396
Practice Address - Fax:978-677-7244
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA39324225700000X
MA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist