Provider Demographics
NPI:1598377939
Name:WILSON, STEVEN (PT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56540 MCFALL PL
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-7788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-7919
Practice Address - Country:US
Practice Address - Phone:217-224-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-007014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist