Provider Demographics
NPI:1437632031
Name:WILSON, MINA (OTR)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 SADIE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6683
Mailing Address - Country:US
Mailing Address - Phone:214-683-5361
Mailing Address - Fax:
Practice Address - Street 1:1643 LANCASTER DR STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3593
Practice Address - Country:US
Practice Address - Phone:817-329-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist