Provider Demographics
NPI:1548590839
Name:WILSON, SANTANA M (LATC)
Entity Type:Individual
Prefix:MISS
First Name:SANTANA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26A GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-2620
Mailing Address - Country:US
Mailing Address - Phone:207-381-7941
Mailing Address - Fax:207-729-6225
Practice Address - Street 1:275 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2671
Practice Address - Country:US
Practice Address - Phone:207-729-4998
Practice Address - Fax:207-729-6225
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT3632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer