Provider Demographics
NPI:1528567906
Name:WILSON, KRISTEN
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLEVELAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-3700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 CLEVELAND AVE
Practice Address - Street 2:SUITE
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112
Practice Address - Country:US
Practice Address - Phone:276-352-4465
Practice Address - Fax:276-293-1212
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist