Provider Demographics
NPI:1558537977
Name:WILSON, LAURA KATHLEEN (DPT)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:KATHLEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10738 RIVERSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2372
Mailing Address - Country:US
Mailing Address - Phone:818-766-4307
Mailing Address - Fax:
Practice Address - Street 1:10738 RIVERSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2372
Practice Address - Country:US
Practice Address - Phone:818-766-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1154410225100000X
CA298343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist