Provider Demographics
NPI:1457682023
Name:WILSON, JUDITH A (COTA)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6011 SE TOWER DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7615
Mailing Address - Country:US
Mailing Address - Phone:772-286-7895
Mailing Address - Fax:772-286-7894
Practice Address - Street 1:6011 SE TOWER DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7615
Practice Address - Country:US
Practice Address - Phone:772-286-7895
Practice Address - Fax:772-286-7894
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 9292224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant