Provider Demographics
NPI:1346631884
Name:WILSON, MICKENZIE FARRELL (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MICKENZIE
Middle Name:FARRELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 ROSSINI ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5552
Mailing Address - Country:US
Mailing Address - Phone:702-292-8160
Mailing Address - Fax:
Practice Address - Street 1:366 E MESA VERDE LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1812
Practice Address - Country:US
Practice Address - Phone:702-227-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15-0549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist