Provider Demographics
NPI:1376716639
Name:WILSON, KRISTIE MAE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:MAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 S BALDWIN RD
Mailing Address - Street 2:STE E
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-2164
Mailing Address - Country:US
Mailing Address - Phone:248-390-6422
Mailing Address - Fax:
Practice Address - Street 1:4405 S BALDWIN RD
Practice Address - Street 2:STE E
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2164
Practice Address - Country:US
Practice Address - Phone:248-390-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist