Provider Demographics
NPI:1407132657
Name:WILSON, SUE A
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3108
Mailing Address - Country:US
Mailing Address - Phone:716-870-1433
Mailing Address - Fax:716-668-8022
Practice Address - Street 1:928 FRENCH RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-3632
Practice Address - Country:US
Practice Address - Phone:716-668-8021
Practice Address - Fax:716-668-8022
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024993-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist