Provider Demographics
NPI:1619142262
Name:WILSON, GREGORY STEPHEN (OT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:STEPHEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N 56TH STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139
Mailing Address - Country:US
Mailing Address - Phone:215-435-8830
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVENUE
Practice Address - Street 2:STAFFING PLUS
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041
Practice Address - Country:US
Practice Address - Phone:610-525-4000
Practice Address - Fax:610-526-6750
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0C000608L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist