Provider Demographics
NPI:1417262205
Name:WILSON, TINA (LMT, CLT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15019 NW 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2828
Mailing Address - Country:US
Mailing Address - Phone:352-494-4372
Mailing Address - Fax:
Practice Address - Street 1:15019 NW 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:FL
Practice Address - Zip Code:32669-2828
Practice Address - Country:US
Practice Address - Phone:352-494-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA31099172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C1960OtherBC/BS