Provider Demographics
NPI:1407966401
Name:BARKWELL-WILSON, RENEE (PT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BARKWELL-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 1:200 FRONT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1559
Mailing Address - Country:US
Mailing Address - Phone:607-754-1776
Mailing Address - Fax:607-748-5465
Practice Address - Street 1:200 FRONT ST
Practice Address - Street 2:SUITE D
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1559
Practice Address - Country:US
Practice Address - Phone:607-754-1776
Practice Address - Fax:607-748-5465
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01544901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1774478Medicaid
NY1774478Medicaid