Provider Demographics
NPI:1598381881
Name:WILSON, MARIE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W 7TH AVE STE 223
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4050
Mailing Address - Country:US
Mailing Address - Phone:405-334-8208
Mailing Address - Fax:
Practice Address - Street 1:116 W 7TH AVE STE 223
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4050
Practice Address - Country:US
Practice Address - Phone:405-334-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172463225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK81-0884055Medicaid