Provider Demographics
NPI:1508159229
Name:WILSON, KIMBERLY RENAE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:RENAE
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 1:208 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9463
Mailing Address - Country:US
Mailing Address - Phone:318-507-9909
Mailing Address - Fax:
Practice Address - Street 1:208 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-9463
Practice Address - Country:US
Practice Address - Phone:318-507-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3055225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics