Provider Demographics
NPI:1598952046
Name:WILSON, ASHLEY MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 SWEETGUM RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-7958
Mailing Address - Country:US
Mailing Address - Phone:574-223-2167
Mailing Address - Fax:
Practice Address - Street 1:668 SWEETGUM RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-7958
Practice Address - Country:US
Practice Address - Phone:574-223-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003555A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant