Provider Demographics
NPI:1578186441
Name:WILSON, MICHAEL D (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-5347
Mailing Address - Country:US
Mailing Address - Phone:337-824-8287
Mailing Address - Fax:337-824-8290
Practice Address - Street 1:7406 HIGHWAY 1 STE 102
Practice Address - Street 2:
Practice Address - City:MANSURA
Practice Address - State:LA
Practice Address - Zip Code:71350-4204
Practice Address - Country:US
Practice Address - Phone:318-240-7680
Practice Address - Fax:318-240-7681
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist