Provider Demographics
NPI:1598522872
Name:WILSON, TRINITY MORENO (PTA)
Entity Type:Individual
Prefix:
First Name:TRINITY
Middle Name:MORENO
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TRINITY
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2712 SANTA BONITA LN
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-3498
Mailing Address - Country:US
Mailing Address - Phone:512-632-4671
Mailing Address - Fax:
Practice Address - Street 1:2000 S MAYS ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7531
Practice Address - Country:US
Practice Address - Phone:512-632-4671
Practice Address - Fax:512-492-3729
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2124227225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant