Provider Demographics
NPI:1346560521
Name:WILSON, SCOTT CULLEN (MS)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:CULLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WILKINSON RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3470
Mailing Address - Country:US
Mailing Address - Phone:973-722-6822
Mailing Address - Fax:
Practice Address - Street 1:36 WILKINSON RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-3470
Practice Address - Country:US
Practice Address - Phone:973-722-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00285100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist